Every finding on record at Rockwell Park Rehabilitation and Healthcare Center

Based on observations and staff interviews, the facility failed to discard a damaged box of frozen food exposed to air in 1 of 1 walk-in freezer and reseal leftover food, and discard dented canned goods stored for use in 1 of 1 dry goods storage room. These practices had the potential to affect food served to residents. The findings included:An initial tour of the kitchen occurred on 9/14/26 at 9:50 AM with the Dietary Manager. The following concerns were identified: a. A cardboard box containing green beans with a hole approximately two inches long on the side of the box with a torn plastic bag inside the box, leaving green beans exposed to air, was observed in the walk-in freezer.b. The following items were observed in the dry goods storage:-one five-pound bag of egg noodles open to air,-one 111 ounce can of pinto beans with approximately a one-inch dent on the side of the can near the rim in rotation for use,-one six-pound, eight ounce can of marinara sauce with approximately a one-inch dent on the top rim in rotation for use.An interview with the Dietary Manager on 9/17/26 at 12:51 PM revealed he had been in his role at the facility for three weeks. He stated he typically unloaded the cans in the dry storage, but he was off the previous week, and another staff member unloaded the cans. The Dietary Manager revealed he had the expectation that the noodles and all other opened items in dry storage should be resealed. He stated he was unsure how the hole in the box of green beans occurred but had the expectation the green beans would have been discarded. An interview with the Administrator on 9/17/26 at 2:12 PM revealed she had the expectation dented cans should be removed, any open food items should be resealed, and any damaged boxes of food should be discarded.

Based on record review, resident and staff interviews, the facility failed to accurately code current tobacco use on the Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for accuracy of assessments (Resident #38).The findings included:Resident #38 was admitted to the facility on [DATE].Resident #38's care plan revised on 7/14/2026 had a focus area for utilizing a vape and cigarettes. Interventions included Resident #38 would adhere to the tobacco/smoking policies of the facility, the facility would conduct a smoking safety evaluation on admission and as needed, educate resident/responsible party (RP) on the facility's tobacco/smoking policies, ensure vape was charged, provide smoking apron if Resident #38 choose to smoke a cigarette and Resident #38 required supervision with smoking.A significant change MDS assessment for Resident #38 dated 8/24/2026 was coded No for Current Tobacco Use. The significant change MDS indicated Resident #38 was moderately cognitively impaired.An interview with Resident #38 on 9/15/2026 at 11:40 AM indicated he smoked cigarettes and vaped. Resident #38 stated he had smoked since admission to the facility.A telephone interview with the MDS Coordinator on 9/17/2026 at 10:49 AM stated she obtained information required for the completion of the MDS from a review of the resident's medical record, a visual assessment/observation of the resident, and discussions held during daily morning clinical meeting. The MDS Coordinator reported Resident #38 was care planned as a supervised smoker and should have been coded as Yes for current tobacco use. The MDS Coordinator stated the section had been coded No in error. An interview with the Director of Nursing (DON) on 9/17/2026 at 1:43 PM indicated she did not complete the MDS assessment so she did not know about the correct coding. The DON stated she knew Resident #38 was a supervised smoker.An interview with the Administrator on 9/17/2026 2:07 PM revealed she expected the MDS assessment for Resident #38 to be accurate and reflect Resident #38's current tobacco use.

Based on record review and staff, Family Member #1, Family Member #2, Hospital Case Manager, and Regional Ombudsman interviews, the facility failed to readmit Resident #93 after being transferred to the hospital for an evaluation for agitation, wandering and unsteady gait for 1 of 3 residents reviewed for inappropriate discharges (Resident #93).Findings included: Resident #93 was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances, dysphagia, and chronic kidney disease. Resident #93 was discharged on 2/28/26. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 was severely cognitively impaired and required assistance from staff with all activities of daily living (ADL). Resident #93 was not coded for any behaviors. The MDS indicated he was not coded for any discharge planning and wished to remain in the facility long-term.A review of Resident #93's care plans created on 2/3/26 revealed a focus area for the need and preference for long-term care placement due to medical, functional, and psychosocial needs. Interventions included addressing psychosocial, medical, and functional needs through individualized care planning, informing Resident #93 of rights, facility routines, and available resources, and providing emotional support and counseling to assist with adjustment to long-term care. Further review of care plans created on 2/3/26 revealed Resident #93 was a risk for wandering and elopement. Interventions included engaging in purposeful activity, identifying wandering and elopement deescalation behaviors, and providing reorientation to surroundings and environment.A review of Resident #93's Electronic Medical Record (EMR) revealed Resident #93 was given a 30-day discharge notice signed by the Administrator on 2/26/26 with a discharge date of 3/28/26. The reason for discharge was selected as it is necessary for your welfare and your needs cannot be met in this facility. The discharge location was to Resident #93's home address. A copy of a revised 30-day discharge notice signed by the Administrator on 2/26/26 included the same information as the previous 30-day discharge notice but had a handwritten note next to the discharge date of 3/28/26 which read or sooner with appropriate placement which has been found at [name redacted] memory care [address redacted]. Resident has been accepted for placement as of 2/26/26. The revised 30-day discharge notice revealed the listed discharge location was Resident #93's home.A review of a nursing progress note written on 2/28/26 by Nurse #5 revealed Resident #93 had increased confusion throughout the night and an unsteady gait. Nurse #5 noted Resident #93's agitation had become more violent toward staff, and he got as close as he could and tried to swing at staff. Nurse #5 noted she felt Resident #93 needed to be seen in the Emergency Room. Resident #93's Responsible Party was notified and Resident #93 left with emergency medical services (EMS). A telephone interview with Nurse #5 on 3/25/26 at 9:14 AM revealed she was Resident #93's nurse the morning of 2/28/26 when he was sent to the Emergency Room. She stated Resident #93 had been up all night, agitated, wandering and had unsteady gait. Nurse #5 reported at one point during the night he was falling into the wall while walking. She stated she called the medical provider and an order was given to send him to the emergency room for evaluation. Nurse #5 stated she called Family Member #1 to alert her to Resident #93's transfer to the hospital.A nursing progress note written on 2/28/26 by the Former Director of Nursing (DON) revealed the Former DON spoke with another Case Manager at the hospital regarding Resident #93. The Case Manager told the Former DON that Resident #93 needed to return to the facility on 2/28/26. The Former DON told the Case Manager that Resident #93 would not be returning due to safety concerns. The Former DON let the Case Manager know that the Regional Ombudsman was involved and understood the concern. The Former DON provided the Regional Ombudsman's name to the Case Manager.A review of email communication that included the Regional Ombudsman, the Administrator, the Social Worker (SW), and the Former DON revealed the SW sent a copy of the amended 30-day discharge notice on 2/28/26 at 4:14 PM to the Regional Ombudsman after Resident #93 was taken to the emergency room earlier that morning. The Regional Ombudsman stated in her email response on 3/2/26 at 10:28 AM that she had already been alerted by the Hospital Discharge Planner that Resident #93 was in the Emergency Room. The Regional Ombudsman sent a follow up email to include the Administrator, the Former DON, and the SW on 3/2/26 at 2:09 PM. The Regional Ombudsman stated the Hospital Case Manager informed her that Resident #93 was in the emergency room and was not admitted and unless Resident #93's family wanted to move him directly to the memory care, the obligation of the facility was to readmit him and have a sitter until he could move. The Administrator responded to the email on 3/2/26 at 2:13 PM and stated Resident #93 had been accepted to the memory care, and she was not sure if his family had visited the facility yet. The Regional Ombudsman responded on 3/2/26 at 3:19 PM that the Hospital Case Manager asked if the facility would readmit Resident #93 until the family had decided about the memory care. The Administrator responded on 3/2/26 at 2:37 PM stating Resident #93's family was at the facility and wanted to appeal the 30-day discharge notice. The Regional Ombudsman responded to the email on 3/2/26 at 2:38 PM and asked if Resident #93 was going to return to the facility later that day. The Administrator responded on 3/2/26 at 2:53 PM that she guessed so and asked the Former DON if staffing was in place for one-on-one care for Resident #93. The Former DON responded 3/2/26 at 3:14 PM that the facility was not able to take Resident #93 back. The Regional Ombudsman responded over email on 3/2/26 at 3:18 PM that the hospital could file a complaint with the State Survey Agency regarding Resident #93's readmission.A review of Resident #93's hospital record revealed he was brought to the emergency room on 2/28/26 for abnormal gait and increased agitation. The records further revealed he was medically cleared for discharge later in the day on 2/28/26 and it was noted Resident #93 was not an imminent threat to himself or anyone else. The hospital records noted Resident #93's family planned to bring him to the facility, but the facility would not allow him to return her phone conversation with the Former DON. Resident #93's hospital notes further revealed the Case Manager contacted the Regional Ombudsman on 2/28/26 due to the facility not readmitting Resident #93 while under a 30-day discharge notice written on 2/26/26. The hospital records revealed Resident #93 was discharged from the hospital on 3/6/26 to his home with Family Member #1.A combined telephone interview with Resident #93's Family Member #1 and Family Member #2 on 3/24/26 at 2:46 PM revealed Resident #93 had received a discharge notice on 2/26/26. Family Member #2 stated the memory care facility that came to assess Resident #93 was not an acceptable placement for him, but Resident #93's family was actively working to find another location. Family Member #1 stated she received a call the morning of 2/28/26 from Nurse #5 that Resident #93 was being sent to the hospital due to being unsteady on his feet and not knowing his name. Family Member #2 reported the facility would not readmit Resident #93 and he stayed in the emergency room until 3/6/26 when Family Member #1 took him home until Resident #93's family found another facility for placement. Family Member #2 stated Resident #93 remained at home until placement at another memory care facility occurred on 3/17/26.A telephone interview with the Hospital Case Manager on 3/26/26 at 8:18 AM revealed Resident #93 arrived at the emergency room on 2/28/26 and was medically cleared for discharge later that day. The Hospital Case Manager stated Resident #93 was under a 30-day discharge notice issued on 2/26/26 from the facility and when the facility was contacted to readmit him on 2/28/26, the Former DON refused to take him back. She stated Resident #93 remained in the emergency room until 3/6/26 when his family took him home and eventually found placement in a memory care facility.A telephone interview with the Regional Ombudsman occurred on 3/26/2026 at 9:49 AM. She stated she was made aware of Resident #93's transfer to the hospital from the Hospital Case Manager when she returned to her office on 3/2/26 from the weekend. The Regional Ombudsman stated she emailed the facility management staff to inform them of Resident #93's right to return to the facility and the Former DON stated the facility would not readmit him. She stated she reminded the facility management staff that the Hospital Case Manager may file a complaint with the State Survey Agency for failure to readmit Resident #93.An interview with the SW on 3/26/26 at 10:21 AM revealed she started working at the facility at the tail end of Resident #93's stay at the facility. She stated she sent the revised 30-day discharge notice to the Regional Ombudsman on 2/28/26 with a memory care facility location after a video assessment was completed with the memory care. The SW stated that the Regional Ombudsman told the facility staff over email that they should take Resident #93 back from the hospital.A telephone interview with the Former DON occurred on 3/26/26 at 1:27 PM. She stated Resident #93 had exhibited many behaviors to include wandering, agitation, and delusions and he would be better suited for a smaller environment like a memory care. The Former DON stated discissions were held with Family Member #1 and Family Member #2 about Resident #93 moving to another facility and the family was not agreeable to a move and wanted him to stay at the facility. The Former DON stated Resident #93 was sent to the emergency room on 2/28/26 for a change in condition regarding an unsteady gait and increased agitation and Resident #93 was given a 30-day discharge notice on 2/26/26 for 30 days or until another facility was found. She stated the Regional Ombudsman agreed that he could go from the hospital to the new facility. A telephone interview with the Administrator on 3/27/26 at 10:03 AM revealed Resident #93 had increasing behaviors such as agitation, wandering and eventually hypersexual behaviors towards staff. She stated Resident #93 was seen by psychiatric services and the Interdisciplinary Team (IDT) decided on a 30-day discharge notice to another facility such as a memory care. The Administrator stated Resident #93's family disclosed to them that Resident #93 was in a memory care facility in the past. She stated the facility located a memory care placement for Resident #93 and Family Member #1 and Family Member #2 were going to go look at it. The Administrator noted she told Family Member #1 2/26/26 that the facility was going to send Resident #93 to her home and Family Member #1 wanted to look at other facility placements. The Administrator stated Resident #93 was sent to the hospital for evaluation on 2/28/26 and she was told by the Regional Ombudsman by email that it was up to the facility to decide about readmitting Resident #93, but the facility may have to take Resident #93 back from the hospital.

Based on record review and staff interviews, the facility failed to develop an individualized comprehensive care plan to include immobilizer care for 1 of 1 resident reviewed for positioning and mobility (Resident #14).The findings included:Resident #14 was admitted to the facility on [DATE] with diagnoses that included fracture of upper end of right tibia (shin bone). A physician's order dated 2/17/2026 for a right lower extremity knee immobilizer to be worn at all times and removed for skin checks and hygiene, with the right lower extremity maintained in extension. The order further instructed staff to document skin integrity every morning and at bedtime, related to a fracture of the upper end of the right tibia and to notify the provider if the skin was not intact.Resident #14's comprehensive care plan dated 2/17/2026 revealed no goals or interventions related to the right knee immobilizer. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 was cognitively intact. An interview was conducted on 3/24/2026 at 1:55 PM with Nurse #4 who was assigned to Resident #14. Nurse #4 stated she did not know if Resident #14 was care planned for her knee immobilizer and stated the resident should have a care plan in place. On 3/26/2026 at 9:24 AM, an interview was conducted with Nurse #3 who was the Unit Manager of the [NAME] and North units. Nurse #3 stated that upon admission, the nurse who completes the admission assessment, the MDS Coordinator and the Director of Nursing (DON) review the orthopedic orders to determine care needs for the resident. She stated anything related to the resident's care should be reflected in the care plan. Nurse #3 indicated she was not aware that Resident #14's knee immobilizer was not on the care plan, and she did not know how it was missed. During an interview with the MDS Coordinator on 3/25/2026 at 10:16 AM, he confirmed that he developed comprehensive care plans for residents based on diagnoses, triggers from the MDS, medical records, and he visited the residents in their room upon admission. The MDS Coordinator stated he did not recall seeing a right knee immobilizer on Resident #14 when he spoke with her. He confirmed interventions related to the right knee immobilizer should be in Resident #14's care plan, which was an oversight on his part. An interview conducted with the Director of Nursing (DON) on 3/25/2026 at 10:34 AM. She stated the MDS Coordinator developed care plans that were reviewed and discussed by the interdisciplinary team during morning and care plan meetings. Resident #14's right knee immobilizer was a significant part of her care and should have been included in the comprehensive care plan.

Based on observations, record review and resident and staff interviews, the facility failed to provide a safe transfer using the mechanical lift for 1 of 4 residents reviewed for accidents (Resident #8).The findings included: A review of the manufacturer's instruction manual dated 2015 for the mechanical lift provided by the facility read in part: When using the lift for a bed transfer, position the legs under the bed and open the legs to a widened position for stability. Do not position the lift by pushing or pulling on the lift arm or the patient. Resident #8 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, right below the knee amputation, abnormalities of gait/mobility and muscle weakness. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact, had lower extremity range of motion impairment on both sides, and required substantial to maximal assistance with transfers. The care plan dated 10/30/25 indicated Resident #8 had an activities of daily living self-care deficit due to right below knee amputation and required 2-person assistance and the use of a mechanical lift for transfers. An incident report dated 12/15/25 completed by the Former Director of Nursing (DON) revealed Nurse Aide (NA) #1 and NA #2 were transferring Resident #8 into bed using the mechanical lift and while attempting to position the resident over the center of the bed, the lift tipped to the side and the arm of the lift hit NA #1 in the chest and came to rest on Resident #8's left knee. Resident #8 was assessed by Nurse #1 and the Former DON, had no complaints of pain or discomfort and no visible injuries were noted. The Nurse Practitioner (NP) was notified, and an order was received to obtain an x-ray of Resident #8's left knee as a precautionary measure. An interview was conducted with NA #1 on 3/24/26 at 2:16 PM. NA #1 stated on 12/15/25 sometime after lunch, NA #2 requested assistance transferring Resident #8 into the bed using the mechanical lift. She indicated NA #2 was positioning the lift beside the bed and she was helping position Resident #8 over the center of the bed when the lift tipped to the side. She stated the arm of the lift hit her in the chest and came to rest on Resident #8's left leg. NA #1 revealed Resident #8 was approximately two inches above the bed and was laid down onto the mattress when the lift tipped. NA #1 revealed she and NA #2 placed the lift back into an upright position and notified Nurse #1 of the incident. She stated Resident #8 had no complaints of pain and was not injured during the incident. NA #1 indicated she was holding on to the lift pad to guide Resident #8 over the center of the bed but did not recall pulling on the lift sling and thought the lift tilted because it was off balance due to not being positioned correctly on the other side of the bed. A phone interview was conducted with NA #2 on 3/25/26 at 10:08 AM revealed she was assigned to Resident #8 on 12/15/25 from 7:00 AM to 3:00 PM. She stated at approximately 1:30 PM she requested NA #1 assist her with transferring Resident #8 into bed using the mechanical lift. NA #2 indicated she lifted Resident #8 out of the wheelchair with the mechanical lift and was positioning the lift on the left side of the bed while NA #1 went on the other side of the bed to help position Resident #8 over the center of the bed. NA #2 revealed before she had the lift positioned correctly with the legs horizontally under the bed, NA #1 began pulling on the lift sling attempting to center Resident #8 over the bed which caused the lift to tilt over, and the arm of the lift hit NA #1 in the chest and came to rest on Resident #8's leg. NA #2 stated she and NA #1 were able to pull the lift back into an upright position and called Nurse #1 from the room. She indicated Nurse #1 immediately responded, assessed Resident #8 and then notified the Former DON of the incident. NA #2 revealed Resident #8 had no complaints of pain and was not injured. Nurse #1 was no longer employed at the facility and unavailable for an interview. An interview was conducted with Resident #8 on 3/24/26 at 1:57 PM. Resident #8 stated he did not recall the exact date, but a few months ago NA #1 and NA #2 were transferring him into bed using the mechanical lift and it tipped sideways, and the lift arm hit NA #1 in the chest and came to rest on his left knee. Resident #8 indicated he was about two inches above the bed and when the lift tilted to the side he was lowered down on the mattress. Resident #8 revealed he had no pain or discomfort and was not injured during the incident. Resident #8 had a physician order dated 12/15/25 to obtain an x-ray of the left knee. The x-ray results report dated 12/15/25 revealed Resident #8's left knee arthroplasty was intact and there was no acute fracture or injury. An investigation summary dated 12/15/25 written by the Former DON revealed NA #1 and NA #2 were transferring Resident #8 into bed using the mechanical lift when the lift tilted and the arm of the lift hit NA #1 in the chest and came to rest on Resident #8's left knee. During a reenactment it was determined the mechanical lift was positioned beside the bed with the legs parallel to the bed and not horizontally underneath the bed, and NA #1 and NA #2 were pulling on the lift sling to position Resident #8 over the center of the bed which caused the lift to tilt. A phone interview was conducted with the Former DON on 3/25/26 at 1:41 PM. She stated on 12/15/25 Nurse #1 notified her immediately that an incident occurred while Resident #8 was transferred into bed with the mechanical lift. The Former DON stated she responded to Resident #8's room and he was lying in bed, had no complaints of pain or discomfort and no visible injuries. The Former DON indicated she obtained statements from NA #1 and NA #2 and had them perform a reenactment of what occurred. The Former DON revealed NA #2 was positioning the lift beside the left side of the bed with the legs parallel to the bed and NA #1 was on the right side of the bed pulling on the lift sling to position Resident #8 over the center which caused the lift to tilt. The Former DON stated the mechanical lift legs should have been placed horizontally underneath the bed and been widened or opened to provide stability before NA #1 attempted to position Resident #8 over the bed and should not have been pulling on the lift sling to position the resident. An interview conducted with the Administrator on 03/26/26 at 12:00 PM revealed nursing staff should follow the facility's mechanical lift policy and operate the mechanical lift per the manufacturer's instructions to ensure residents were transferred in a safe manner. The facility provided the following corrective action plan. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 12/15/2025, Nurse Aide (NA) #1 and Nurse Aide (NA) #2 were transferring Resident #1 from the wheelchair to the bed. The mechanical lift legs were positioned parallel to Resident #1's bed and not under the bed separated and locked per the manufacturer's recommendations and when NA #1 and NA #2 attempted to position Resident #1 over the center of the bed the mechanical lift tilted and the arm of the lift hit NA #1 in the chest and came to rest on Resident #1's left knee. On 12/15/2025, Nurse #1 immediately assessed Resident #1 and had no complaints of pain or visible injuries. Resident #1 was also assessed by the Director of Nursing and noted to be without injury or complaints of pain. On 12/15/2025, the Nurse Practitioner was notified of the incident, and orders were received to obtain an x-ray of Resident #1's left knee as a precautionary measure. On 12/15/2025, Nurse #1 notified the Resident Representative of the incident and order to obtain x-ray as precautionary measure. On 12/15/2025, The x-ray was obtained of a Resident #1's left knee and the results showed the left knee arthroplasty was intact and there were no injuries. On 12/15/2025 the mechanical lift that was used to transfer Resident #1 was removed from service by the Director of Nursing, inspected by the Maintenance Director and was in good working order with no concerns were identified. On 12/15/2025 Nursing Aide (NA) #1 and Nursing Aide (NA) #2 were immediately re-educated by the DON on the facility mechanical lift policy, and proper use of the mechanical lift which included positioning the mechanical lift and lift legs per the manufacturer's instructions, adjusting the mechanical lift height for resident safety during movement, slowly lifting the resident, only lifting as high as necessary to complete transfer, proper positioning of the resident at the transfer destination (bed, chair etc.), slowly lowering resident to their ending position (sitting upright in wheelchair, laying in the bed, etc.), removing any objects prior to lifting resident (fall mats, trash cans, wires, etc.) and inspecting the mechanical lift and lift equipment prior to use to ensure it was in proper working order. On 12/15/2025, the Director of Nursing completed mechanical lift transfer competencies for Nursing Aide (NA) #1 and Nursing Aide (NA) #2 with all competencies met and no concerns identified. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents using mechanical lifts have the potential to be affected. On 12/15/2025 the Regional Clinical Director and the Director of Nursing reviewed the facility Mechanical Lift Policy. No changes were implemented. On 12/15/2025, the Maintenance Director completed a 100% audit of all mechanical lifts. All lifts were in proper working order and no concerns were identified. On 12/15/2025 the Director of Nursing/Designee interviewed residents with a Brief Interview for Mental Status (BIMs) score of 13 or higher that per the care plan and Kardex utilized a mechanical lift to ensure no safety issues with transfers. No concerns were identified. This was completed on 12/16/2025. On 12/15/2025 the Director of Nursing/Designee completed a head-to-toe skin assessment for all residents that utilize a mechanical lift to ensure no injuries or issues occurred related to transfers. No concerns were identified. This was completed on 12/16/2025. On 12/15/2025 the Director of Nursing/Designee reviewed care plans for all residents that utilize mechanical lifts to ensure transfer status was documented accurately. No concerns were identified. This audit was completed on 12/16/2025. On 12/15/2025 The Regional Clinical Director reviewed all incident reports for the last 30 days to ensure there were no incidents related to transfers using mechanical lifts. No concerns were identified. This audit was completed on 12/16/2025. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 12/15/2025, the Director of Nursing/Designee began re-educating all nursing staff on the facility mechanical lift policy, and proper use of the mechanical lift which included positioning the mechanical lift and lift legs per the manufacturer's instructions, adjusting the mechanical lift height for resident safety during movement, slowly lifting the resident, only lifting as high as necessary to complete transfer, proper positioning of the resident at the transfer destination (bed, chair etc.), slowly lowering resident to their ending position (sitting upright in wheelchair, laying in the bed, etc.), removing any objects prior to lifting resident (fall mats, trash cans, wires, etc.) and inspecting the mechanical lift and lift equipment prior to use to ensure it was in proper working order. This was completed on 12/18/2025. Nursing staff that did receive this education by 12/18/2025 will receive the education prior to the start of their next shift and the Director of Nursing will be responsible for ensuring they receive the education. On 12/15/2025 the Director of Nursing/Designee completed mechanical lift competencies with all Licensed Nurses and all Nurse Aides (NA). This was completed on 12/18/2025. Nursing staff that did not complete a mechanical lift competency by 12/18/2025 will complete prior to the start of their shift. The Director of Nursing will be responsible for ensuring competencies are completed prior to the start of the next shift. Mechanical lift competencies will be completed during the facility orientation program for all newly hired nursing staff and will be the responsibility of the Director of Nursing. An ADHOC Quality Assurance Performance Improvement (QAPI) Committee meeting was held on 12/16/2025. A Root Cause Analysis was completed and determined that the mechanical lift was not in the correct position with the legs not being under the bed prior to positioning the resident. The QAPI committee discussed, reviewed and approved the correction plan that was initiated by the Regional Clinical Director and the Director of Nursing on 12/15/2025 and decided on how to monitor the plan going forward. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. Beginning 12/22/2025 the Director of Nursing/Designee will observe 2 lift transfers weekly on all three shifts for 12 weeks to ensure proper use of the mechanical lift, including ensuring proper mechanical lift positioning. This will be completed on 3/15/2026. The DON or designee will be responsible for reporting results of these audits to the facility's monthly QAPI committee meeting for 3 months. The QAPI committee will make recommendations and changes as indicated based upon the findings of these audits. Compliance Date: 12/19/2025 The facility's corrective action plan was validated on 3/26/26. A phone interview conducted with the Former DON revealed on 12/15/25 through 12/18/25 she provided education to all nursing staff on the facility's mechanical lift policy and proper use of the mechanical lift and observed all nursing staff perform return demonstration of a safe resident transfer using the mechanical lift with no concerns identified. An interview conducted with the Maintenance Director indicated on 12/15/25 he inspected all the facility's mechanical lifts, and all the lifts were in good working condition. Interviews conducted with NA #1 and NA #2 revealed on 12/15/25 the Former DON provided education on the facility's mechanical lift policy and proper use of the mechanical lift during a resident transfer, and they were observed by the Former DON performing return demonstration of a safe resident transfer using the mechanical lift. Interviews conducted with Nurses and NAs revealed they received education on the facility's mechanical lift policy and proper use of the mechanical lift and performed return demonstration of a safe resident transfer using the mechanical lift. A review of the facility's audit records revealed observations of lift transfers were completed twice a week on all three shifts from 12/22/25 through 3/15/26 and no concerns were identified. An observation was conducted on 3/26/26 of two NAs transferring Resident #8 from the wheelchair into bed using the mechanical lift. The NAs used the mechanical lift per the manufacturer's instructions and transferred Resident #8 safely into bed with no concerns identified. The facility's compliance date of 12/19/25 was validated.

Based on observations and staff interviews, the facility failed to remove expired medications stored in 2 of 3 medication rooms reviewed for medication storage (Medication Room for [NAME] Hall and Over the Counter (OTC) Medication Storage Room) and failed to date a vial Tuberculin Purified Protein Derivative (PPD) used for tuberculosis testing when opened in 1 of 2 medication refrigerators (West Hall Medication Room refrigerator).The findings included:An observation of the Over the Counter Medication Storage room was conducted on 3/24/2026 at 2:49 PM in the presence of Unit Manager #1. The following medication was found in the medication room: four boxes of bisacodyl suppositories (a medication used as a stimulant laxative for constipation)10 milligrams (mg) with 12 suppositories per box. The expiration date on the boxes was November 2025. Unit Manager #1 confirmed the expiration date by reading aloud the date printed on the box. An interview with Unit Manager #1 was completed on 3/24/2026 at 2:49 PM. Unit Manager #1 stated the Over-the-Counter Medication Room was checked frequently by the Central Supply staff member. She stated typically if nurses removed a medication from the medication room they would ensure it was not expired prior to administration. An interview with Central Supply Staff Member #1 was completed on 3/25/26 at 10:09 AM. Central Supply Staff Member #1 confirmed that he stocked the Over the Counter Medication Storage room weekly as well as checked for expiration dates on the medication stored in the room. He stated he checked the room the week prior and did not see the expired bisacodyl suppositories.An observation of the [NAME] Medication Storage room was conducted on 3/24/2026 at 3:05 PM in the presence of Unit Manager #2. The following medication was found in the medication room: two bottles of Calcium 600 mg 60 tablets per bottle (a dietary supplement medication). The expiration date on the bottles was February 2026. Unit Manager #2 confirmed the expiration date by reading aloud the date printed on the bottles.An observation of the [NAME] Medication Storage room was continued on 3/24/26 at 3:10 PM in the presence of Unit Manager #2. The following medication was found in the refrigerator of the medication storage room: a vial of aplisol (tuberculin PPD, diluted) 5 TU/0.1 milliliter. The vial was opened and undated. Unit Manager #2 confirmed the vial was opened and undated. An interview with Unit Manager #2 was completed on 3/24/2026 at 3:15 PM. Unit Manager #2 stated that the Unit Managers were responsible for checking the medication rooms including the refrigerator for expired medications weekly and a night shift nurse should also check the medication room each night shift. Unit Manager #2 reported that if an expired medication was found, a return form should be completed and placed in the return tote for the pharmacy to pick up on night shift. The interview revealed Unit Manager #2 had checked the Medication room the week prior and had overlooked the expired medication. She stated the tuberculin vial should have been dated once it was opened and placed back into the refrigerator. An interview conducted with the Director of Nursing (DON) on 3/25/2026 at 9:54 AM revealed that the Unit Managers were responsible for checking the medication expiration dates weekly in the medication rooms including the refrigerator. She also stated the Unit Managers were responsible for the Over-the-Counter medication storage room. The DON indicated nursing staff was expected to check the medication expiration date prior to placing it on their medication carts or administering it to residents. The DON explained all medication vials should be dated when opened and were only good for a duration of 28 days per the facility policy. The DON stated without an open date on the vial of tuberculin serum the facility would not know if the medication was expired or not. An interview was completed on 3/25/2026 at 10:51 AM with the Administrator. The Administrator stated the Medication Storage rooms should have been checked on a weekly basis for expiration dates. If a medication had expired, it should have been removed from the medication storage room. The Administrator indicated any vials of medication that had been opened should be dated when it was opened and used.

Based on record review, observations and staff interviews, the facility failed to follow their infection control policy and procedures for Contact Precautions when Nurse Aide (NA) #3 did not wear all necessary Personal Protective Equipment (PPE) while providing incontinence care for Resident #53. The deficiency occurred for 1 of 4 staff members observed for infection control practices (NA #3).The findings included:A review of the facility's policy that was revised in October 2018 titled Contact Precautions, indicated:Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves will be removed and hand hygiene performed before leaving the room. Staff will avoid touching potentially contaminated environmental surfaces or items in the residents' room after gloves are removed. Staff and visitors will wear disposable gown upon entering the room and remove gloves and gown before leaving the room and avoid touching potentially contaminated surfaces or items in the resident's room after gloves are removed. An observation of Resident #53's room door occurred on 3/23/2026 at 11:00 AM. Resident #53's room had a Contact Precaution sign posted on the front of the door, and personal protective equipment (PPE) was hanging next to the Contact Precaution sign. The Contact Precaution sign located on Resident #53's door revealed that all healthcare personnel must wear gloves and a gown when entering the resident's room and remove before leaving the room. An observation of Nurse Aide (NA) #3 finishing up incontinence care for Resident #53 occurred on 3/23/2026 at 11:00 AM. NA #3 was wearing gloves but did not have a gown on. An interview with NA #3 on 3/23/2026 at 11:04 AM revealed she was aware that Resident #53 was on Contact Precautions. NA #3 confirmed she had just completed incontinence care for Resident #53. NA #3 stated, I was moving fast and just forgot to put a gown on. NA #3 stated she had received infection control training last week (week of 3/16/2026). On 03/25/2026 at 2:59 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who was also the Infection Preventionist (IP). The ADON/IP confirmed Resident #53 was on Contact Precautions for Extended Spectrum Beta-Lactamase (ESBL-infection of the urine). The ADON/IP explained that when Contact Precaution signage was posted outside a resident's door, all staff were required to wear a gown and gloves upon each entry into the room for any activity. The ADON/IP stated that all staff were educated on new precautions through multiple methods, including monthly town hall meetings, communication boards, phone notifications, and direct education from supervisors on each shift. The ADON/IP confirmed that the most recent town hall meeting was held on 3/19/2026 and that all staff were educated and expected to attend which included NA #3. The ADON/IP confirmed that Nurse Aides were required to wear a gown and gloves when providing incontinence care to Resident #53. The ADON/IP further stated that there was no acceptable reason for staff not to follow the policy. On 03/25/2026 at 3:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff were expected to follow the precaution signage posted on residents' doors and adhere to the required PPE indicated. The DON reported that staff education was provided through skills fairs and monthly town hall meetings. The DON stated that during the most recent town hall on 03/19/26, topics reviewed included use of PPE as indicated on door signage. The DON confirmed that all shifts and staff had received this education including NA #3. The DON stated that she would want staff to always wear the required PPE when indicated. The DON stated that Nurse Aides may rush to attend to other time-sensitive residents. The DON further stated that staff should feel comfortable asking for assistance when needed to ensure proper care and adherence to infection control protocols. An interview was conducted on 3/26/2026 at 9:36 AM with Nurse #2 who was assigned to Resident #53 on 3/23/2026. Nurse #2 stated that the required personal protective equipment (PPE) depended on the residents' precautions. She stated, Contact Precautions consisted of a gown, gloves, and whatever the door sign instructed. Nurse #2 confirmed Resident #53 was on Contact Precautions for ESBL. Nurse #2 stated that she did not observe any instances on 03/23/2026 of Nurse Aides failing to wear the appropriate PPE while providing care to Resident #53. Nurse #2 further stated that if she were to observe a Nurse Aide not wearing the appropriate PPE, she would instruct them to put on the required PPE per facility protocol. An interview was conducted on 03/26/2026 at 9:46 AM, with the Administrator. The Administrator stated that proper procedure required staff to put on appropriate PPE when precaution signage was posted outside a resident's door. The Administrator reported that staff training on infection control and PPE use was provided during orientation, annually, as needed, and through ongoing methods such as town hall meetings and skills fairs. The Administrator confirmed that all staff were included in this training. The Administrator stated that Nurse Aides should follow established protocols. The Administrator further stated that NA #3 should have worn a gown for compliance with the posted precautions.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to provide safe transport for a resident in a wheelchair when Nurse #1 transported Resident #1 in a wheelchair to the medication cart while Resident #1 held her legs up because she was unable to bend them and place them on the wheelchair footrests. Resident #1's left leg dropped down between the wheelchair footrests and got caught underneath the wheelchair. Resident #1 was complaining of severe pain to her left leg with swelling noted to her left shin and was transferred to the emergency department (ED) for further evaluation. X-rays obtained in the ED revealed Resident #1 sustained a left proximal (upper) tibia (shinbone) fracture and her left leg was placed in a splint and she returned to the facility with orders for hydrocodone/acetaminophen 5-325 milligrams two tablets administered every 6 hours as needed to manage her pain. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), osteoporosis, muscle weakness, and vascular dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired, was dependent on staff for transfers and mobility, used a manual wheelchair and had lower extremity range of motion impairment on both sides. The care plan dated 10/03/25 indicated Resident #1 was dependent on staff for assistance with all activities of daily living due to a diagnosis of cerebral infarction and often refused to get out of bed.An incident report dated 11/22/25 at 2:30 PM completed by Nurse #1 revealed several visitors arrived at the facility to celebrate Resident #1's birthday and her room was too small to accommodate them, so they requested a larger place to meet and for Resident #1 to be transferred out of bed into a wheelchair. Resident #1 initially refused to get out of bed but finally agreed after continued encouragement from the visitors and staff. Nurse #1 and Nurse #2 used the mechanical lift to transfer Resident #1 from the bed into a wheelchair, but she was unable to bend her legs to place them on the wheelchair footrests due to stiffness and pain. Nurse #1 asked Resident #1 to hold her legs up so she could transport her in the wheelchair to the medication cart to administer pain medication. Resident #1 agreed and Nurse #1 transported her approximately 30 feet when she heard her yell out my leg. Nurse #1 stopped the wheelchair and observed that Resident #1's left leg had fallen between the wheelchair footrests and got caught underneath the wheelchair. Nurse #1 slowly rolled the wheelchair backwards to remove Resident #1's left leg from underneath the chair and noted Resident #1 was complaining of pain and had swelling to her left shin. Nurse #1 called 911, notified the on-call provider and obtained an order to transport Resident #1 to the ED for further evaluation. Resident #1 remained in the wheelchair and was administered acetaminophen 650 milligrams (mg) for pain and when emergency medical services (EMS) arrived at the facility, she was transported to the emergency department (ED) for further evaluation. The incident report further noted the contributing factor to Resident #1's injury was due to positioning in the wheelchair.An interview conducted with Nurse #1 on 1/06/26 at 11:35AM revealed she was assigned to Resident #1 on 11/22/25 7:00 AM to 3:00 PM. She stated several of Resident #1's family members arrived at the facility after lunch to celebrate her birthday and her room was too small to accommodate them, so they requested a larger place to meet, and she recommended the facility's library. She indicated the family agreed to gather in the facility's library and requested for Resident #1 to be transferred out of bed into a wheelchair. She stated Resident #1 usually refused to get out of bed but after continued encouragement from family and staff she agreed. Nurse #1 indicated Nurse #2 assisted her and they transferred Resident #1 from her bed to the wheelchair using the mechanical lift. She stated Resident #1's legs were stiff, she was complaining of leg pain and was unable to bend her legs to place them on the wheelchair footrests. Nurse #1 revealed she was rushing because the family was waiting, and asked Resident #1 to just hold her legs up so she could take her to the medication cart to administer pain medication and then bring her to the library. Nurse #1 revealed she transported Resident #1 in the wheelchair approximately 30 feet and was approaching the medication cart when Resident #1 yelled out my leg. Nurse #1 revealed she stopped the wheelchair and observed that Resident #1's left leg had fallen between the footrests and was caught underneath the wheelchair. She revealed she slowly rolled the wheelchair backwards to remove Resident #1's leg from under the chair and assessed her for injury. Nurse #1 stated Resident #1 was complaining of left leg pain, and her left shin was swollen. Nurse #1 revealed she was concerned Resident #1's leg was broken so she immediately called 911 and then called the on-call provider and obtained an order to transport Resident #1 to the ED for further evaluation. Nurse #1 indicated she administered acetaminophen to Resident #1 for pain and did not move or reposition her until EMS arrived. Nurse #1 revealed Resident #1 was diagnosed with a left tibia fracture in the ED and returned to the facility the same day, but it was after her shift ended. She stated Resident #1 had a soft splint in place on her left leg, was at her baseline and her pain was well managed. Nurse #1 indicated she was not aware of any previous episodes of Resident #1 not being able to bend her legs when she was transferred into the wheelchair and she thought her legs were stiff due to not getting out of bed for long periods of time. Nurse #1 revealed she should have given Resident #1's legs time to relax or used a different chair that could support her legs, but her family was waiting and she felt rushed.A review of the ED records dated 11/22/25 revealed Resident #1 was evaluated for an injury due to her left leg getting caught under a wheelchair. X-rays obtained in the ED revealed Resident #1 had an acute fracture of the left proximal tibia and also noted diffuse osteopenia (weakening of the bones). Due to Resident #1's non-ambulatory status prior to the injury surgery was not indicated and her left leg was placed in a splint for comfort. Resident #1 was discharged back to the facility with orders for hydrocodone/acetaminophen 5-325 mg every 6 hours as needed for pain and to schedule a follow up appointment with orthopedic. A nurse's note dated 11/22/25 at 9:53 PM written by the Director of Nursing (DON) revealed Resident #1 returned to the facility with a left lower leg splint and orders for hydrocodone/ acetaminophen 5-325 mg every 6 hours as needed for pain and to schedule a follow up with orthopedic.The Medical Director's note dated 11/24/25 indicated Resident #1 was transferred to the ED 11/22/25 due to a leg injury and diagnosed with an acute left proximal tibia fracture. Resident #1 was observed lying in bed comfortably with a left leg splint in place and had no complaints of pain. New orders were given to administer hydrocodone/ acetaminophen 5-325 mg two tablets every 6 hours for pain for 14 days and to follow up with orthopedic as needed.A review of Resident #1's physician orders and medication administration record (MAR) revealed the following:1/13/25 acetaminophen 325 milligrams (mg) give 2 tablets by mouth every 6 hours as needed for pain or fever. The MAR indicated it was administered on 11/22/25 at 3:01 PM, 11/25/25 at 4:00 PM and 11/26/25 at 3:20 AM.11/22/25 hydrocodone/acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain. The MAR indicated it was administered on 11/22/25 at 11:50 PM and 11/23/25 at 10:05 AM.11/24/25 hydrocodone/acetaminophen 5-325 mg give 2 tablets by mouth every 6 hours for pain for 14 days.An orthopedic visit note dated 11/26/25 revealed Resident #1 was evaluated due to left proximal tibia fracture. Resident #1's left leg was placed in a long leg splint and was to remain in place until follow up appointment in 4 weeks for repeat x-raysAn orthopedic visit note dated 12/23/25 indicated x-rays obtained of Resident #1's left leg revealed no significant changes to the fracture and orders were given for long leg splint to remain in place until next follow up appointment in 4 weeks.An interview was conducted with the DON on 1/06/26 at 3:01 PM. She stated she was notified of the incident that occurred with Resident #1 on 11/22/25 and was at the facility when she returned from the ED. She revealed Resident #1 was diagnosed with a left tibia fracture and was placed in a soft splint. The DON indicated Resident #1 was at her baseline and her pain was well managed. She stated prior to the incident the wheelchair was appropriate to use for Resident #1 when she was out of bed, and she was not aware of any concerns related to her not being able to bend her legs. She indicated Resident #1 last used the wheelchair on 10/29/25 for an appointment outside of facility and was transported in the chair without incident. The DON revealed Nurse #1 transporting Resident #1 in the wheelchair when she was unable to bend her legs to place them on the footrests was unsafe.During a phone interview with the Medical Director on 1/06/26 at 3:40 PM he revealed he was notified on 11/22/25 that Resident #1 was evaluated in the ED and diagnosed with a left tibia fracture. He stated during a follow-up visit on 11/24/25 he assessed Resident #1 to be at her baseline, her pain was well managed, and she was exhibiting no signs of discomfort. The Medical Director revealed Resident #1 was immobile and had a diagnosis of osteoporosis which significantly increased her risk of fractures.A phone interview conducted with the Former Administrator on 1/06/26 at 4:00 PM indicated the DON notified him on 11/22/25 of the incident that occurred involving Resident #1. The Former Administrator revealed Resident #1 was not transported in the wheelchair safely and should not have been transported in the chair without her legs being placed on the footrests.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:On 11/22/2025 at approximately 2:00 pm 15-20 family members of Resident #1 arrived at the facility. Family demanded resident get up out of bed. Resident #1 refused but later agreed to get up in the wheelchair due to so many family members present to celebrate her birthday. At approximately 2:45 pm Nurse #1 and Nurse #2 assisted Resident #1 out of bed to Resident #1's personal wheelchair, using a mechanical lift. Resident #1 was complaining of pain while sitting in the wheelchair. Nurse #1 placed leg rest on wheelchair and positioned Resident #1 in the wheelchair, however Resident #1 could not bend her knees to place her feet on the leg rest. Resident #1 was positioned with her legs sticking straight out. Nurse # 1 assisted Resident #1 out of her room in the wheelchair, approximately 30 feet to the medication cart to administer ordered pain medication, at which time Resident #1 dropped her left leg, causing her leg to go slightly beneath the wheelchair and between the attached leg rest. On 11/22/2025 Nurse #1 immediately assessed Resident #1, which included a pain assessment and vital signs.On 11/22/2025 Nurse #1 immediately notified the family for Resident #1 who was in the facility.On 11/22/2025 Nurse #1 contacted the on-call physician and received orders to transport Resident #1 to the emergency room. On 11/22/2025 at approximately 3:30 pm Resident #1 was transported to the emergency room via Emergency Medical Services (EMS). On 11/22/2025 at approximately 9:45 pm Resident #1 returned to the facility with a diagnosis of a tibial fracture of the left leg. On 11/22/2025 the Director of Nursing assessed Resident #1 upon return from the hospital without pain medication orders.On 11/22/2025 at approximately 9:50 pm the Director of Nursing contacted the emergency room for pain medication orders for Resident #1. On 11/22/2025 at approximately 10:00 pm the Director of Nursing obtained Resident #1s pain medication from the local pharmacy.On 11/22/2025 the Regional Clinical Director reviewed the care plan for Resident #1 to ensure the care plan reflected accurate transfer status. No concerns were identified.On 11/23/2025 at approximately 2:00 pm the facility in house Nurse Practitioner assessed Resident #1, orders were received to schedule pain medication every 6 hours.On 11/23/2025 the Director of Maintenance verified the wheelchair for Resident #1 was in proper working order. This included the wheelchair wheels, brakes and footrest. No concerns were identified.On 11/23/2025 the facility Occupational Therapist evaluated Resident #1 for proper seating and positioning when out of bed and recommended the use of a geri-chair. The Director of Nursing communicated the change to Resident #1's assigned nurse and NA and updated the kardex and care plan so all nursing staff were aware, and a geri-chair was placed in Resident #1's room.Address how the facility will identify other residents having the potential to be affected by the same deficient practice:All residents that utilize wheelchairs have the potential to be affected.On 11/22/2025, the Regional Clinical Director and the Director of Nursing reviewed the facility Wheelchair Positioning and Transport Policy and Procedure. No revisions were required.On 11/23/2025 the Minimum Data Set (MDS) Coordinator reviewed the residents' most recent MDS assessment to ensure appropriate mode of transport was addressed in the care plan. Any concerns were immediately addressed. On 11/23/2025 the Director of Nursing completed competencies and return demonstration for Nurse #1 and Nurse #2 related to proper positioning and safe transport of a resident in a wheelchair. The competencies reviewed included wheelchair positioning/transportation, brakes locked before transfer, footrest in place before transport, feet properly placed on footrest before/during transport, ensure feet do not slip during transport, ensure resident is comfortable, position resident with hips back, pelvis neutral (pelvis is balanced, not tilting forward or backwards), trunk supported, feet on footplates and transport at a safe/controlled speed.On 11/23/2025 the Director of Maintenance completed a 100% audit of all resident wheelchairs to ensure proper functioning, including wheels, brakes and footrest. Any concerns were immediately addressed.On 11/23/2025 the Director of Rehabilitation completed a review of all facility wheelchairs to ensure wheelchairs were functional and footrest were available as indicated per resident needs.On 11/22/2025 and 11/23/2025 the Director of Nursing/Designee completed wheelchair competencies which included wheelchair positioning/transportation, brakes locked before transfer, footrest in place before transport, feet properly placed on footrest before/during transport, ensure feet do not slip during transport, ensure resident is comfortable, position resident with hips back, pelvis neutral (pelvis is balanced, not tilting forward or backwards), trunk supported, feet on footplates transport at a safe/controlled speed for all Licensed Nurses and Nursing Aides (NAs), Activities, Therapy, Transportation, Receptionist, and department managers, including Nursing Home Administrator, Medical Records, Maintenance Director, Rehab Manager, Activities Director, Admissions Director, Human Resource Director and Business Office Manager. All staff that were not available will have competencies completed prior to the start of their next shift and this will be the responsibility of the Director of Nursing. This was completed on 11/23/2025.On 11/23/2025 the Director of Nursing/Designee informed all residents' responsible parties per letter delivered by the United States Postal Service Mail to notify the facility as soon as possible, preferably within 24 hours, if a group of 5 or more visitors are visiting at the same time, to ensure the resident is ready and provisions can be made for a safe and comfortable visit. On 11/24/2025 & 11/25/2025 the facility Occupational Therapist completed seating and positioning screens for all current residents in wheelchairs. The Director of Nursing/designee communicated any changes to the residents' assigned nurse and updated the care plan and kardex accordingly. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:On 11/22/2025, the Director of Nursing began immediate education with all staff, including all Licensed Nurses and Nursing Aides (NAs), Activities, Therapy, Transportation, Receptionist, and department managers, including Nursing Home Administrator, Medical Records, Maintenance Director, Rehab Manager, Activities Director, Admissions Director , Human Resource Director and Business Office Manager using the facility Wheelchair Transport Policy and Procedure and Wheelchair Positioning Policy and Procedure. This education included:Before moving a resident:- Ensure both brakes are locked: if brakes do not lock, do not use wheelchair.- Verify the resident is properly positioned.- Confirm footrest are even and the appropriate length (as indicated)- Confirm footrests are down and residents' feet will not slip off of footrest.General Transport Rules:- Unlock brakes before transport.- Inform the resident before movement.- Keep both hands on wheelchair handles.- Move at a safe, controlled speed.- Ensure extremities remain inside the wheelchair.- Avoid sharp turns or sudden stops.Wheelchair positioning:-Verify wheelchair setup (brakes, footrests, cushion placement).-Position resident with hips back, pelvis neutral (pelvis is balanced, not tilting forward or backwards), trunk supported, feet on footplates.-Apply positioning devices as ordered.On 11/22/2025 the Director of Nursing educated all Nurse Aides (NAs) on reviewing the kardex for all their assigned residents prior to each shift for any updates or changes. The kardex, located in the electronic medical record, is updated by the DON/Designee as indicated with any changes.On 11/22/2025 the Director of Nursing educated all Licensed Nurses and Nursing Aides (NA's) to not transfer or transport residents in a wheelchair if there were any of the following concerns and to notify the Director of Nursing/Therapy so the resident's seating/mode of transportation can be evaluated for appropriateness and safety: -Resident is not comfortable during transfer or in the wheelchair-Resident is unable to place feet on the footrest correctly or comfortably, due to confusion, pain, contractures, wounds, etc.-Resident is unable to be positioned safely with hips back, pelvis is balanced, not tilting forward or backwards, trunk is supported, feet are placed on the footrest without sliding or falling off.-Footrests are not even and/or are not the appropriate length-Resident complains of pain or discomfort when placed in wheelchair and pain or discomfort is unrelieved by repositioning.-Resident cannot wear proper footwear, such as non-slip shoes, gripper socks, etc. -Wheelchair is in disrepair: has broken or sharp edges, brakes do not lock (do not place resident in wheelchair if brakes do not lock), pushing the wheelchair is difficult due to wheels not functioning properly.All education was completed on 11/23/2025. Any employee that was not educated will receive the education prior to their next shift and the Director of Nursing/Designee will be responsible for providing the education. The education will also be added to the facility orientation program for all new hires. An ADHOC Quality Assurance Performance Improvement Committee Meeting was held on 11/24/2025 to discuss, review and approve the plan that had been initiated and implemented by the Regional Clinical Director and the Director of Nursing on 11/22/2025. The Quality Assurance Performance Improvement Committee also reviewed the policy and procedure for Wheelchair Transport and Wheelchair Positioning. The decision to monitor the plan was also decided upon during the Quality Assurance Performance Improvement Committee meeting on 11/24/2025. Root Cause Analysis was completed and determined that Nurse pushed resident in wheelchair while her legs were extended straight out and not on footrests. Resident should have been placed in an alternative chair relating to stiffness and inability to bend legs accordingly on this day.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained include dates when corrective action will be completed:The Director of Nursing/Designee starting on 12/01/25 will observe 3 residents during transfers to the wheelchair weekly for 12 weeks to ensure proper positioning per policy, preference and comfort.The Director of Nursing/Designee starting on 12/01/25 will observe 3 wheelchair transports by staff weekly for 12 weeks to ensure proper transportation per policy.The Director of Rehab/Designee starting on 12/01/25 will audit 3 wheelchairs weekly for 12 weeks to ensure proper function and footrest are available as indicated per resident needs.The Director of Nursing/Designee starting on 12/01/25 will review competencies for wheelchair positioning and transfers for all newly hired staff weekly for 12 weeks to ensure competency completion.The Director of Nursing/Designee and the Director of Rehabilitation/Designee will be responsible for reporting the results of these audits to the facility's monthly QAPI committee meeting for 3 months. The QAPI committee will make recommendations and changes as indicated based upon the findings of the audits.The facility alleged compliance as of 11/26/2025.The facility's corrective action plan was validated on 1/06/26. An interview conducted with the Director of Maintenance revealed he completed an audit of all the facility's wheelchairs on 11/23/25 to ensure they were working properly including Resident #1's wheelchair and no concerns were identified. During an interview with the Director of Rehabilitation she stated on 11/23/25 the occupational therapist assessed Resident #1 for proper seating when out of bed and recommended the use of a geri-chair which was placed in Resident #1's room. The Director of Rehabilitation indicated she also completed an audit of all the facility's wheelchairs to ensure they were functional and had compatible footrests, and the occupational therapist evaluated Resident #1 and determined a ger The Director of Rehabilitation further stated on 11/24/25 and 11/25/25 seating and positioning screens were completed by occupational therapy for all residents in wheelchairs and the DON was notified of any changes or recommendations, so the resident care plans were updated. Interviews were conducted with nursing, housekeeping and dining staff revealed they received education on the facility's Wheelchair Transport Policy and Procedure and Wheelchair Positioning Policy and Procedure which included proper wheelchair positioning, general rules for transporting a resident safely in a wheelchair and ensuring footrests were used. Observations conducted of staff transporting residents in wheelchairs revealed no concerns related to positioning or safety and footrests were observed being used. The facility's alleged compliance date of 11/26/25 was validated.

Based on observations, record review, and staff and resident interviews, the facility failed to honor a resident's choice to smoke a tobacco cigarette by making residents use vaping devices for 4 of 4 residents reviewed for choices (Resident #42, Resident #23, Resident #18 and Resident #78). This deficient practice had the potential to affect all residents that smoked cigarettes.The findings included: The facility's smoking policy revised on 9/19/25 read in part: This facility is a safe smoking facility, and the use of tobacco products is limited to e-cigarettes and vaping devices and permitted only in designated areas.a. Resident #42 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was moderately cognitively impaired, was able to understand and be understood by others and was coded for current use of tobacco. The care plan dated 9/19/25 indicated Resident #42 had a focus area related to tobacco use and the interventions included supervision when smoking and utilizing a smoking apron for safety. The safe smoking evaluation dated 11/11/25 revealed Resident #42 required supervision while smoking. During an observation and interview with Resident #42 on 11/18/25 at 2:15 PM he was observed vaping in the facility's designated smoking area. Resident #42 stated approximately a month ago the facility smoking policy changed and only vaping was allowed. He revealed he was not given the option to continue smoking tobacco cigarettes, which was his preference, and he did not like vaping. b. Resident #23 was admitted to the facility on [DATE]. The annual MDS dated [DATE] revealed Resident #23 was moderately cognitively impaired, was able to understand and be understood by others and was not coded for current tobacco use. The care plan dated 10/21/25 indicated Resident #23 had a focus area related to tobacco use and the interventions included supervision when smoking and utilizing a smoking apron for safety. The safe smoking evaluation dated 11/11/25 revealed Resident #23 required supervision when smoking. An interview conducted with Resident #23 on 11/19/25 at 12:25 PM revealed the facility recently changed their smoking policy and residents were only allowed to vape. Resident #23 revealed she wanted to smoke tobacco cigarettes and was not able to vape because it made her sick. c. Resident #18 was admitted to the facility on [DATE]. The annual MDS dated [DATE] revealed Resident #18 was cognitively intact and was coded for current tobacco use. The care plan dated 9/26/25 indicated Resident #18 had a focus area related to tobacco use and the interventions included supervision when smoking and utilizing a smoking apron for safety. The safe smoking evaluation dated 11/11/25 revealed Resident #18 required supervision when smoking. During an observation and interview on 11/19/25 9:29 AM Resident #18 was observed vaping in the facility's designated smoking area. He stated the facility recently changed the smoking policy to only allow vaping and he was not given the choice to continue smoking tobacco cigarettes. Resident #18 revealed he did not like vaping and wanted to smoke cigarettes.d. Resident #78 was admitted to the facility on [DATE]. The admission MDS dated [DATE] revealed Resident #78 was cognitively intact and coded for current tobacco use. The care plan dated 5/15/25 indicated Resident #78 had a focus area related to tobacco use and the interventions included supervision when smoking and utilizing a smoking apron for safety. The safe smoking evaluation dated 11/11/25 revealed Resident #78 required supervision when smoking. An interview was conducted with Resident #78 on 11/19/25 at 11:20 AM. Resident #78 stated the facility recently changed their smoking policy to only allow vaping and if she wanted to continue smoking tobacco cigarettes she would have to move to another facility. Resident #78 revealed she did not like vaping and if she had a choice she would smoke cigarettes. During an interview with the Administrator on 11/19/25 at 1:17 PM he revealed the facility implemented a new smoking policy on 10/20/25 due to concerns related to residents not holding lit cigarettes safely and increased difficulty for staff supervising residents during the scheduled smoking times. He indicated the new policy allowed residents to vape or use e-cigarettes, but smoking tobacco cigarettes was no longer permitted. The Administrator stated residents were initially informed of the new smoking policy in the Resident Council Meeting on 9/19/25 and then weekly meetings were held to remind them of the upcoming change. The Administrator indicated residents that did not want to vape or use e-cigarettes were offered smoking cessation options or to move to a facility that permitted the use of tobacco cigarettes and was accepting new residents.

Based on record review, and Responsible Party and staff interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to increasing the frequency for 1 of 5 residents reviewed for unnecessary medications (Resident #62).The findings included:Resident # 62 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was rarely/never understood and had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #62 had physical behavioral symptoms directed towards others and other behavioral symptoms not directed towards others which occurred 4 to 6 days during the assessment period. Resident #62 also had verbal behavioral symptoms directed towards others and rejection of evaluation or care behaviors which occurred 1 to 3 days during the assessment period. The MDS further indicated that Resident #62's current behavior status was worse compared to the prior assessment. Resident #62 received antipsychotics and antianxiety medications.A review of Resident #62's Physician Orders indicated an active order dated 6/23/25 for ABH gel (Lorazepam 0.5 milligrams/Diphenhydramine 12.5 milligrams/Haloperidol 1 milligram) which changed from twice daily to three times a day for anxiety. The order read to apply 1 milliliter topically to inner aspect of wrist.A review of Resident #62's medical record indicated an electronic psychotropic medication informed consent form completed by Unit Manager #1 on 10/2/25 about the use of ABH gel three times a day. The form indicated that Resident #62's Responsible Party (RP) gave a verbal consent to the use of ABH gel for Resident #62.A phone interview with Resident #62's RP on 11/18/25 at 2:18 PM revealed she was not aware what an ABH gel was. The RP stated the nurses had not discussed with her about Resident #62 receiving this medication and they had not talked to her about its risks and benefits. Resident #62's RP stated that she wished they would discuss with her any changes in Resident #62's medications, and that she was not aware that they had increased the frequency of the medication.An interview with Unit Manager #1 on 11/19/25 at 11:57 AM revealed she completed the psychotropic medication consent form on 10/2/25 after a care conference meeting with Resident #62's RP over the phone. Unit Manager #1 stated that all she could remember telling Resident #62's RP was that Resident #62 was still receiving the ABH gel and the RP asked her if it was working, and she told her that it was as long as it was given in a timely manner. Unit Manager #1 stated that Resident #62' RP knew about Resident #62 receiving the ABH gel, but she did not discuss with the RP about the risks and benefits of using the ABH gel, and she could not remember if she told her that they had increased the frequency in June 2025.A follow-up interview with Unit Manager #1 on 11/20/25 at 9:46 AM revealed she entered the order change for Resident #62's ABH gel on 6/23/25 but she could not remember if she obtained a consent from Resident #62's RP prior to entering the order. Unit Manager #1 stated she should have obtained the consent, but she couldn't remember whether they had started obtaining psychotropic medication consents at that time.An interview with the Director of Nursing (DON) on 11/20/25 at 10:19 AM revealed the process that they followed regarding psychotropic medication consents was when the nurses get the order for psychotropic medications or changes, they need to call the RP or guardian and obtain a consent prior to starting the medication or implementing the change. The DON stated they had noticed as they were looking at different processes at the facility around August 2025 that a number of psychotropic medication consents were not obtained or in place prior to starting therapy. The DON stated that she knew a care plan meeting was completed on 10/2/25 where the ABH gel was discussed with Resident #62's RP, but she agreed that the consent should have been obtained prior to increasing the dose in June 2025.

Based on record review and staff interviews, the facility failed to revise a resident's care plan when her smoking status changed for 1 of 18 residents reviewed for comprehensive care plans (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus.A review of Resident #9's most up-to-date care plan revealed a focus area indicating tobacco use- and Resident #9 was assessed to be an unsafe and supervised smoker with a revision date of 8/19/24. Interventions included conducting smoking safety evaluation on admission and as needed and utilizing a smoking apron.A review of Resident #9's electronic medical record (EMR) revealed a smoking assessment dated [DATE] which indicated Resident #9 as a non-smoker who did not use smokeless tobacco products or electronic cigarettes. The assessment also revealed Resident #9 quit smoking in the previous month and wished to remain non-smoking.A review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #9 was cognitively intact and was not coded for tobacco use.An interview with Resident #9 on 11/19/2025 at 2:50 PM revealed she made the decision to quit smoking by herself last summer because she knew smoking was bad for her.An interview with MDS Nurse 11/20/2025 at 2:22 PM revealed any changes in a resident's smoking status would be discussed in the clinical portion of the management's morning meeting. The MDS Nurse indicated he would update the care plan and MDS if a status changed.

Based on record review, observations and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of medications to the wrong resident (2 medication errors out of 26 opportunities), resulting in a medication error rate of 7.69% for 1 of 5 residents (Resident #62) observed during medication pass.The findings included:Resident #62 was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis (condition where there is breakdown of cartilage in multiple sites throughout the body) and constipation.The Physician's Orders in Resident #62's electronic medical record indicated an active order dated 11/17/23 for Polyethylene Glycol oral powder give 17 grams orally one time a day for constipation - mix with 4 to 8 ounces of fluid and an active order dated 6/26/25 for Acetaminophen liquid 160 milligrams (mg)/5 milliliters - give 650 mg by mouth three times a day for osteoarthritis.A review of Resident #32's Physician's Orders did not include Polyethylene Glycol and Acetaminophen to be given at 9:00 AM.On 11/19/25 at 10:30 AM, Nurse #1 was observed as she prepared to administer Resident #62's medications. Nurse #1 entered Resident #62's room but walked over directly to Resident #32. As she attempted to give Resident #62's Acetaminophen liquid to Resident #32, Resident #32 pushed the cup away but did not say anything. The surveyor asked Nurse #1 if she was sure she was giving the medication to the right resident and Nurse #1 stated that she was sure Resident #32 was Resident #62. Nurse #1 then attempted to give Resident #62's Acetaminophen liquid to Resident #32 who pushed the cup away again. Nurse #1 then stepped outside the room and looked at the resident names by the door. She went to Resident #62's bedside and asked for her name. Resident #62 stated her first name. Nurse #1 then proceeded to administer Resident #62's medications.An interview with Nurse #1 on 11/19/25 at 10:38 AM revealed this was her first time working with Resident #62 and was not familiar with her. Nurse #1 stated that she would look at the names at the door and look at the picture in the Medication Administration Record (MAR) to identify the correct resident, but she did not know what to say about why she identified the wrong resident. Nurse #1 stated that she would have given Resident #62's medications to the wrong resident if Resident #32 did not push the cup away.An interview with Unit Manager #1 on 11/19/25 at 11:57 AM revealed Nurse #1 was probably nervous because she was being observed administering medications. Unit Manager #1 stated Nurse #1 normally worked on the other medication cart and was not familiar with the residents where she was assigned today. Unit Manager #1 stated they had pictures on the MAR and names on the door where the first name was always the resident on the first bed. Unit Manager #1 stated that these should have helped Nurse #1 identify the right resident as well as she should have asked the resident their names before administering medications to them.An interview with the Director of Nursing (DON) on 11/20/25 at 10:19 AM revealed Nurse #1 should have checked the resident identifiers like the picture on the MAR and the names on the door, and asked the resident to state their name before giving their medications. The DON stated the nurses should be checking and verifying that they give medications to the right resident.

Based on observations, record review, and staff, resident, and Medical Director interviews, the facility failed to ensure the necessary supervision was provided to prevent a cognitively impaired resident who was care planned as having a history of attempting to leave the facility, who wandered aimlessly and had impaired safety awareness from exiting the building at night without staff knowledge. On 07/17/25, the resident was last seen at 9:00 PM. At approximately 9:30 PM Nurse Aide (NA) #1 was unable to locate Resident #1. Staff members searched the building before checking the back doorway employee entrance, which required a keycode for exit. Resident #1 was found outside lying on his left side with his wheelchair on top of his lower back area. Resident #1 had traveled approximately 30 feet out of a back employee entrance down a sidewalk that led to a dark dumpster area which was approximately 5 feet from where Resident #1 was found and that staff sometimes used as a parking area. The area of sidewalk where Resident #1 was found was noted to have a large crack in the pavement. The resident was brought back into the building at approximately 10:10 PM. This deficient practice had the high likelihood to cause serious harm or serious bodily injury to Resident #1 including serious head injury, fractures, or internal injuries. The deficient practice affected 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses of heart failure, metabolic encephalopathy and non-Alzheimer's dementia. A current care plan initiated on 04/01/25 revealed a focus area for Resident #1 as an elopement risk/wanderer related to disorientation to place, history of attempts to leave the facility unattended, and impaired safety awareness. Resident #1 was noted to wander the facility aimlessly, significantly intruding on the privacy or activities of other residents. The goal was for Resident #1's safety to be maintained through the next review date. Interventions included distracting the resident from wandering, identifying the pattern of wandering, increased supervision and a wanderguard bracelet (bracelet that causes the door to alarm if a resident exits a door that was equipped with wanderguard alarm sensor) to the resident's ankle. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required moderate assistance of one staff member for sit to stand transfers and chair to bed transfers. Wandering behavior not exhibited during the assessment reference period. Resident #1 used a wheelchair as an assistive device and had no functional impairments with range of motion to the upper or lower extremities. He did not receive an anticoagulant during the assessment period. Resident #1 used a wander/elopement alarm daily. A physician order dated 04/27/25 revealed Resident #1 had a wanderguard. Nursing staff were to check placement of the bracelet to left ankle every shift and monitor the wanderguard each shift. Review of Resident #1's Medication Administration Record dated July 2025 revealed an order for staff to check placement of the bracelet to left ankle every shift and monitor the wanderguard each shift. The order was initialed as completed on each shift by the nursing staff.Review of Resident #1's medical record from June 2025 to July 2025 revealed no progress notes that mentioned Resident #1's wandering behaviors or tendencies. An incident report dated 07/17/25 revealed Resident #1 was found by Nurse #1 on the ground by the employee entrance. Resident #1 stated he was going to the kitchen. The resident was assessed by Nurse #1 and noted to have no injuries at the time of the fall. Resident #1 was assisted into his wheelchair by two staff members The note revealed Resident #1's vital signs were at baseline, range of motion was within normal limits and a head-to-toe skin assessment revealed his skin was intact. Neurological monitoring was initiated. The incident report was completed by Nurse #1. An elopement risk evaluation dated 07/17/25 completed by Nurse #1 revealed Resident #1 scored a level 6 and was labeled as a low risk for potential elopement. A nursing note dated 07/17/25 at 11:16 PM written by Nurse #1 revealed Resident #1's vital signs were the following: blood pressure 164/74 (normal range 120/80), pulse 65 (normal range 60-90), respirations 18 (normal range 12-20) and oxygen saturation level 97% (normal range greater than 92%). Resident #1 was noted to have had a fall from his wheelchair. He was placed back into his wheelchair by two-person assistance with neurological monitoring in place. The residents Responsible Party was notified as well as the on-call provider. On 09/04/25 at 10:04 AM an interview was conducted with Nurse #1. During the interview Nurse #1 stated she was responsible for Resident #1 on 07/17/25 during the 3:00 PM to 11:00 PM shift. Nurse #1 stated Resident #1 was alert but confused and would often wander around the facility in his wheelchair. She stated on 07/17/25 she had administered his nighttime medications at 9:00 PM. Nurse Aide (NA) #1 went to check on Resident #1 at 9:30 PM and noticed he was not in his room. NA #1 went to Nurse #1 and stated she could not find the resident. Nurse #1 stated the facility staff completed the rounds around the inside of the facility. On the first round they checked the hallways, on the second round they checked the resident rooms and on the third round they checked in the resident bathrooms but were unable to locate Resident #1. She stated each staff member in the building was assigned an area to look and she decided to look out of the backdoor which was the employee entrance. The interview revealed the door required a key code to get out of the building and into the building. Nurse #1 stated she entered the key code number and stepped outside of the door, yelling Resident #1's name and heard a response of yeah. The interview revealed it was dark outside, and she could not initially see Resident #1. Nurse #1 stated she walked to the end of the sidewalk to find Resident #1 lying on his left side with the wheelchair on top of his lower back. Nurse #1 stated the time frame of Resident #1 being missing and her finding the resident was approximately 15 minutes. She stated she yelled for staff assistance and Nurse Aide #2 came outside. Nurse #1 assessed Resident #1 and noted him to have no injuries therefore Nurse #1 and NA #2 assisted the resident back into his wheelchair. Nurse #1 stated Resident #1 was smiling and laughing at the situation while they rolled him back into the facility around 10:10 PM. Nurse #1 stated she had to put in the key code to get back into the facility while pushing the resident. Resident #1 stated to Nurse #1 he did not know how he had gotten out of the door and that he was trying to find the kitchen. Resident #1 was placed into his bed and put on every 15-minute monitoring. A one-on-one staff member was placed with the resident once he was back into bed because the facility had an extra nurse that night. Nurse #1 stated she notified the residents Responsible Party, on-call provider and the Director of Nursing. Resident #1 was wearing a t-shirt, pants and non-slip socks with slide on shoes at the time of the elopement. Nurse #1 stated she completed the elopement assessment along with the Director of Nursing and kept the residents score low because he intentionally did not elope from the facility. Resident #1 was confused and was looking for the kitchen. An observation and interview were conducted on 09/04/25 at 10:09 AM with Nurse #1. The observation started at the back door employee exit/entrance and continued outside to where Resident #1 was located the night he exited the facility. The staff time clock was on the wall on the right side of the wall door. Nurse #1 used a keycode located on the inside of the door to open the door, no alarm sounded. The door slowly closed behind the surveyor and Nurse #1 in a time frame a resident could have put his foot in the door to stop it. A STOP sign with education to check your surroundings before exiting the facility was observed on the inside of the door. Once the door was shut, there was a sidewalk leading to the back alley of the facility in an S shape. The kitchen was observed to be straight across from the back door. Nurse #1 explained she could not see Resident #1 immediately when she went out of the door because she could not completely visualize where the sidewalk ended from standing directly on the outside of the door and it was dark outside. Nurse #1 stated she had to walk a couple of feet before being able to visualize the resident lying on the ground with the wheelchair on top of him approximately 30 feet from the door of the facility. Resident #1 was found on the slope leading down from the sidewalk where the sidewalk met the pavement. There was large crack in the sidewalk at the end of the sidewalk where Nurse #1 explained Resident #1's wheelchair must have gotten caught causing it to turn over. A dumpster was located out of the back kitchen area and was approximately 5 feet from where the resident was found lying in the dark. There were no cars parked during the observation however, the back alley-way led to the employee parking lot.A weather report dated 07/17/25 revealed the low for the area was 79 degrees on the night Resident #1 was found outside of the facility. The weather report also indicated the sun set at 8:37 PM. On 09/04/25 at 10:37 AM an observation and interview were conducted with Resident #1. During the interview he stated he did not recall ever going out of the back entrance of the facility or experiencing a fall. He stated he did not remember the incident. Resident #1 was observed lying in bed at the time of the interview.On 09/04/25 at 10:45 AM an interview was conducted with NA #1. NA #1 stated she had worked the 7:00 PM to 7:00 AM shift on 07/17/25 and was responsible for Resident #1. The interview revealed NA #1 had picked up Resident #1's meal tray at 8:30 PM. She stated she went back to check on Resident #1 at 9:30 PM, however she was unable to locate him in his room. NA #1 stated Resident #1 would typically roll around the facility in his wheelchair, so she thought he was probably on the other side of the building, so she started to immediately look for him. NA #1 told Nurse #1 she was unable to locate Resident #1 and Nurse #1 stated, he isn't far, I just gave him his medication at 9:00 PM. The interview revealed the facility staff started checking all resident rooms and bathrooms. By the time everyone in the building was looking for Resident #1, Nurse #1 had gone out of the facility's back entrance and found Resident #1 outside. NA #1 stated when she came back around the building Nurse #1 and NA #2 had the resident in his wheelchair and back inside of the facility. NA #1 stated Resident #1 was smiling and laughing about the situation and did not seem in any distress. Resident #1 was placed into his bed around 10:15 PM and every 15-minute monitoring was initiated. The facility had an extra staff member that came in on the night of the incident and was assigned to Resident #1 for one-on-one supervision. NA #1 stated Resident #1 had been wandering around the facility in his wheelchair per his usual self that night and she had not observed him attempting to exit any of the facility doors. On 09/04/25 at 11:00 AM an interview was conducted with the Director of Nursing (DON). During the interview the DON stated she and the Assistant Director of Nursing (ADON) had been in the facility on 07/17/25 and had clocked out at 9:46 PM and exited the facility together through the back door employee entrance of the facility. The DON stated she used the keycode to exit the door. The interview revealed the DON had parked her vehicle at the back entrance of the facility. The interview revealed there were no residents near the door when she exited the building, nor did she see any residents in the hallway. She stated she received a call from Nurse #1 shortly after leaving around 10:10 PM stating Resident #1 had gotten out of the back door employee entrance and experienced a fall off of the sidewalk. The DON stated she immediately turned around and returned to the facility to assess the situation. She stated once back at the facility she assessed Resident #1 herself and noted no injuries. The DON explained Resident #1 would sometimes follow staff around the building and felt like he had trailed behind someone as they went out the door that night and the staff hadn't seen him. The DON noted she did not see him when she exited the facility at 9:46 PM. She stated she had an extra staff member that night, so they were placed on one on one with Resident #1 and every 15-minute monitoring was initiated. Resident #1's wanderguard was in place at the time of the elopement however the back door employee entrance does not have a wanderguard alarm system, it was a key code only door. The DON explained Resident #1's elopement risk score remained low because she felt like he wasn't trying to elope from the facility, but was confused and looking for the kitchen as he stated. A review of the facility time sheet revealed on 07/17/25 at 9:46 PM the Director of Nursing clocked out of the facility. The Assistant Director of Nursing clocked out of the facility at 9:45 PM. No other staff members locked out during the time frame of 9:00 PM to 9:45 PM. On 09/04/25 at 10:50 AM, 11:15 AM and 2:31 PM an interview was attempted with Nurse Aide #2 with no return phone call received. On 09/04/25 at 3:13 PM an interview was conducted with NA #3. During the interview he stated he had seen Resident #1 in his wheelchair on the night of the incident, but he was not attempting to exit any of the doors that night. NA #3 explained he was working on a different unit than where Resident #1 resided. The interview revealed NA #3 had visualized him trailing close behind staff members in the past, close to the doors and always being in the hallway near the door but did not specifically see him with that behavior on the night of 07/17/25. NA #3 stated all staff in the facility were looking for Resident #1 on the night of the incident and had looked in resident rooms and bathrooms. He stated it wasn't long after the search began that Resident #1 was found outside of the back door employee entrance. NA #3 stated Resident #1 did not seem like he was in distress or hurt when he saw him. He stated the resident was smiling.On 09/04/25 at 3:18 PM an interview was conducted with the Scheduler. During the interview she stated she was not working on the night of 07/17/25 but had observed Resident #1 following staff around closely while they left the building and had experienced him following her. She stated she knew he had a wanderguard bracelet on and she would always turn around to ensure the door closed once she exited the building. The interview revealed that all staff members knew Resident #1 would wander around the building in his wheelchair. On 09/04/25 at 11:54 PM an interview was conducted with the Medical Director. During the interview he stated he was told about the incident the next day by the Director of Nursing. Resident #1 tried to get around the facility himself and he unfortunately snuck out of the back door. The Medical Director stated, there was no harm to it. Resident #1 knew what he was doing when he followed a staff member out of the door and managed to fool the facility staff. The Medical Director explained that Resident #1 was probably having a good day mentally and was able to exit the building. When the Medical Director was asked if Resident #1 was safe to be outside by himself after dark the Medical Director replied that was a trick question, it was a slight problem but not a huge problem. The Medical Director stated he did not expect perfection from the nursing home staff. It was unfortunate but it wasn't the nursing home's fault he got out of the door. On 09/04/25 at 12:31 PM an interview was conducted with the Administrator. He stated he was not in the facility when the incident occurred, however, remembered hearing about it the day after. The interview revealed the Director of Nursing had gone back to assist staff that night on 07/17/25. The Administrator stated it was his understanding Resident#1 was missing for approximately 15 minutes from the facility when he was found outside of the back door employee entrance. He stated the facility had assumed he had followed a staff member out of the door but interviewed all staff members the night of the incident and nobody had seen him behind them when going out of the door. The interview revealed Resident #1 was wearing a wanderguard and all of the other doors in the facility would have alarmed except for the back employee entrance. There was no alarm that night and based on his location it was assumed that he went out through the back door. The interview revealed Resident #1 had not eloped from the facility prior to 07/17/25 or after.The Administrator was notified of the immediate jeopardy on 09/04/25 at 1:39 PM.The facility provided the following corrective action plan with a compliance date of 07/19/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 7/17/2025, at approximately 9:30 PM Nursing Aide (NA) noted that Resident #1 could not be located. The Nurse Aide (NA) reported to Resident #1's nurse that Resident #1 was missing. Resident #1's Nurse verbally alerted the staff nurse on the other nursing unit that Resident #1 was missing and staff on both units immediately began searching for Resident #1 in all rooms, closets, under beds and in bathrooms, shower rooms, clean and soiled utility rooms, day rooms, nursing stations, employee lounge, dining area, kitchen, lobby, and common areas within the center and as well as the outside of the center front, sides and back of the center and parking areas. Resident #1 was located outside the employee exit door on the sidewalk approximately 30 feet from the exit door. Resident #1 had fallen, and his wheelchair was tipped over on top of him. On 7/17/2025 at 10:10 pm the Licensed Nurse completed a head-to-toe skin assessment, including neurological checks and range of motion for Resident #1. No concerns were identified. On 7/17/2025 The Director of Nursing notified the on-call Nurse Practitioner at 11:13 pm. On 7/17/2025 The Director of Nursing notified Resident #1's responsible party. On 7/17/2025 the Regional Clinical Director reviewed the care plan for Resident #1 to ensure the care plan reflected use of wanderguard and wandering/elopement status. No concerns were identified. On 7/17/2025 the Regional Clinical Director reviewed Resident #1's physician orders to ensure orders were in place to check placement of wanderguard and to verify battery function. No concerns were identified. On 7/17/2025 the Director of Nursing verified all doors were secure and locked, including performance test of wanderguard door. No concerns were identified. On 7/17/2025 the Director of Nursing completed an elopement risk assessment for Resident #1 with a score of 6 (low risk). On 7/17/2025 the Director of Nursing verified the wanderguard was in place and the battery was functioning properly for Resident #1. No concerns were identified. On 7/17/2025 Resident #1 was placed on 1:1. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with wandering behaviors have the potential to be affected. On 7/17/2025 the Director of Nursing/Designee completed a 100% resident count to ensure all current residents were present in the facility. No concerns were identified. On 7/17/2025 the Director of Nursing/Designee verified all residents with wanderguards had wanderguards in place and they were functioning properly. No concerns were identified. On 7/17/2025, the Policy and procedure for Wandering and Elopement was reviewed by the Regional Clinical Director and the Director of Nursing. On 7/18/2025 the Maintenance Director checked all exit doors to ensure proper functioning, including the performing a function test on the wanderguard door. No concerns were identified. On 7/18/2025 the Maintenance Director placed signs stating to stop on all exit doors to provide a visual reminder for residents to stop and not exit. This is also a reminder for staff to ensure the door is closed, and residents do not exit doors behind them. On 7/18/2025 the Director of Nursing/Designee completed elopement assessments for all residents. Any residents identified as being at risk for elopement were immediately evaluated for proper interventions, including need for wanderguard, or referral to a memory care/dementia unit. On 7/18/2025 the Regional Clinical Director reviewed/updated care plans and NA's kardex's for all residents at risk for elopement/with a wanderguard. On 7/18/2025 the Regional Clinical Director reviewed physician orders for all residents with wanderguards to ensure orders were in place to check placement of wanderguard and to verify function. No concerns were identified. On 7/18/2025 the Assistant Director of Nursing reviewed and updated the elopement books, as indicated with pictures of residents assessed to be at risk for elopement. These books are located at each nurse's station and the reception desk at the front of the facility and are updated as needed with changes, including new residents at risk for elopement with wanderguard orders and when a wanderguard has been discontinued. These updates are the responsibility of the Director of Nursing/Designee. On 7/18/2025 an elopement drill was completed by the Maintenance Director and the Director of Nursing using the facility Elopement Drill Documentation Audit Form with all staff on duty at the time of the drill. This audit form was provided to the nurses on duty and posted at each facility nurses' station as a guide to elopement protocol steps. This drill included: The Nurse alerts all staff of the missing resident with an announcement Medical Alert- There is a missing Resident. The Resident was last seen on (UNIT). This alerts all staff that a formal search is underway. Each unit sends a person to the unit that announced the code to learn the name and description of the missing residents. Each unit charge nurse directs in-house staff to search room to room and all areas of the center, including all resident rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, laundry, kitchen (including walk-in refrigerators and freezers) bathrooms, dayrooms/lounges, courtyards and employee lounges, outside building perimeter and grounds. Staff successfully responded to missing resident. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 7/18/2025, the Director of Nursing/Assistant Director of Nursing/Designee educated staff using the policy and procedure for Wandering and Elopement, including the Elopement Drill Documentation Audit Form, which also included the following:a. All staff were educated on ensuring residents are not sitting at exit doors- especially if staff are going out of the door: stop signs were placed at every exit door as a visual reminder for residents and staff.b. All staff were educated on ensuring that once outside, staff should make sure the door is closed and locked from the outside and that residents have not followed them outside, as well as check surroundings.c. All staff were educated on ensuring the whereabouts of residents with wandering tendencies routinely throughout the shift.d. All staff were educated on notifying the nurse, Unit Manager/Director or Nursing/Assistant Director of Nursing if residents have new wandering behaviors.e. Licensed Nurses were educated to complete elopement risk assessment, change in condition documentation, and notify the Physician/Nurse Practitioner/Responsible Party, and apply a wanderguard, implement appropriate interventions and update the elopements books located at each nurse's station and the receptionist desk as indicated or with new wandering behavior. f. Licensed Nurses were educated that new admissions/re-admissions should have a wandering/elopement assessment completed upon admission, with appropriate interventions implemented if high risk for elopement. g. Licensed Nurses were educated on verifying wanderguard function daily, including blinking pattern on wanderguard, which indicates proper function of the wanderguard when residents are not near the sensor box wanderguard door (front door). h. All staff were educated on notifying the Nurse/Unit Manager/Director of Nursing/Assistant Director of Nursing if residents are near a wanderguard door, and door does not activate or sound. i. Nursing Aides (NA's) were educated on reviewing kardex for each assigned residents each shift they work for any updates or changes to the residents kardex.j. All staff were educated on the process/policy on how to respond to elopement or missing person. This education was completed on 7/18/2025. Any employee who is not educated will receive this education prior to their next shift. The Director of Nursing/Designee will be responsible for this education. This education will be added to the facility orientation program for all new hires. The Director of Nursing/Designee will validate with the Human Resource Director that all new hires have received this education during the orientation process. An ADHOC Quality Assurance Performance Improvement Committee Meeting was held on 7/18/2025 to discuss, review and approve the plan that had been initiated and implemented by the Regional Clinical Director and the Director of Nursing on 7/17/2025. The Quality Assurance Performance Improvement Committee also reviewed the policy and procedure for Wandering and Elopement residents as well as the Elopement Drill Documentation Audit Form. The decision to monitor the plan was also decided upon during the QAPI meeting on 07/17/25. Root Cause Analysis was completed and determined that Resident #1 likely trailed behind staff that was exiting out the employee entrance/exit door as Resident #1 validated this was the door that was exited, which was the employee door at the back of the facility and verified that the code was not known to Resident #1. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. The Director of Nursing/Designee and/or the Human Resources Director/Designee will randomly observe staff entering/exiting the 2 designated employee entrance/exit doors, which are not wanderguard protected, 3 times a week for 12 weeks. They will observe staff entering or exiting the designated employee entrances door to ensure that staff, during the observations are paying attention to their surrounds, ensuring no residents follow them out of the building, and ensuring the door closes and is locked appropriately. All other entrance/exit doors that are not wanderguard protected have alarms which alert staff when the door has been opened, which are emergency exit doors only and are not designated entrance/exit doors. The Maintenance Director/Designee will perform door checks on all exit doors, including verifying stop signs are in place as well as performing a function test on the wanderguard door 5 times a week for 12 weeks to ensure doors/including wanderguard door function properly. The Director of Nursing/Designee will verify 3 wanderguards are functioning properly weekly for 12 weeks. The Director of Nursing/Maintenance Director were notified by the Regional Clinical Director on 7/17/2025 of their responsibility to conduct elopement drills. These drills will be conducted as follows: 1 drill on each shift for 1 month for a total of 3 drills, then 2 drills a month for 3 additional months to ensure proper staff response. These drills will be conducted unannounced, on random days of the week/shifts/times. The Director of Nursing/Designee will review all new admissions elopement assessments weekly for 12 weeks to ensure proper interventions are implemented. This will include physician notification to obtain orders for interventions, residents responsible party notification, care plan, Nursing Aides (NA's) kardex's, elopement books updates as indicated. The Director of Nursing/Designee will review progress/behavior notes 5 times a week for 12 weeks during clinical morning meeting using the 24 hour report to ensure wandering behaviors have been addressed with proper interventions implemented as indicated. The Director of Nursing/designee and the Maintenance Director will be responsible for reporting the results of these audits to the facility s monthly QAPI committee meeting for 3 months. The QAPI committee will make recommendations and changes as indicated based upon the findings of the audits. Immediate Jeopardy Removal date: 7/19/2025 On 09/04/25, the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed all staff were educated on ensuring that once outside of the facility door, staff should make sure the door was closed and locked from outside and that resident have not followed them outside as well as to check their surroundings. All staff were educated on ensuring the residents whereabouts and notifying nursing staff if residents exhibited new wandering behaviors. Nurses received education on completing the elopement risk assessment, change of condition documentation and who to notify if an incident occurred. Nurses stated they were to verify wanderguard placement daily and functionality of the device. Nurse Aides verified they had received education on reviewing the Kardex for each assigned resident. All staff including dietary staff, maintenance, housekeeping staff and nursing staff were interviewed and confirmed they had received education on the process/policy on how to respond to elopement or a missing resident. The facilities in-service log, monitoring results and training material was reviewed along with audit tools. An observation was conducted of stop signs on the exit doors.The validation verified immediate jeopardy was removed on 07/19/25 and the deficiency was corrected on 07/19/25.

Based on record review, and staff, Family Member #1 and Medical Director interviews, the facility failed to recognize the current treatment plan was not effective and the seriousness of a resident with a diagnosis of hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone) not responding to high doses of levothyroxine (medication used to treat hypothyroidism). As of [DATE] Resident #1 had an active order for an endocrinology consultation for hypothyroidism. On [DATE] lab work was obtained and resulted in a critically high TSH (Thyroid Stimulating Hormone) level of 50.3 (normal range 0.5 to 5.0). The endocrinology consultation order was not faxed by the facility to the consultation office until [DATE] and a referral to an endocrinologist for an evaluation was not scheduled. Resident #1's thyroid medication remained at the same dosage for the month of [DATE] and [DATE] at 225 mcg (microgram) by mouth daily. On [DATE] Resident #1 had a thyroid stimulating hormone (TSH) level of 50.3 (normal range 0.5 to 5.0). A TSH level of 50 is considered critically high and indicates severe hypothyroidism, which can lead to serious health complications if not addressed. A Nurse Practitioner note dated [DATE] revealed Resident #1 was evaluated due to increased confusion and a decrease in appetite. On [DATE] Resident #1 was observed in an unresponsive state at the facility. Emergency Medical Service (EMS) was dispatched to the facility and Resident #1's heart rate was 32 beats per minute (bpm) (normal range 60-100 beats per minute) and a transcutaneous pacemaker (temporary external pacing method used to stimulate the heart to contract by delivering electrical impulses through the chest wall) was placed on Resident #1 by EMS. An improvement in heart rate was noted with a reading of 82 bpm (beats per minute). Upon arrival at the Emergency Department (ED), she was unresponsive, pulseless, with a pulse oximetry (measures the percentage of oxygen in the blood) reading of 7% (normal level 95-100%) and cardiopulmonary resuscitation (CPR) was initiated. She required emergent intubation (medical procedure where a tube is inserted into a windpipe to keep the airway open when a person is unable to breathe on their own) and was placed on a ventilator (a machine utilized to support or take over breathing). Hospital records dated [DATE] revealed Resident #1 was in a severe hypothyroid state with a diagnosis of myxedema coma (a life-threatening endocrine emergency that occurs when thyroid hormone regulation is disrupted). Resident #1's TSH level was 240. Resident #1 was admitted into the intensive care unit (ICU) with continued intubation and ventilation until [DATE]. The deficient practice occurred for 1 of 3 residents reviewed for quality of care (Resident #1). Immediate jeopardy began on [DATE] when Resident #1 had a thyroid stimulating hormone (TSH) level of 50.3 (normal range 0.5 to 5.0) and the facility failed to initiate effective medical treatment. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, acute kidney failure, obstructive uropathy, muscle weakness, hypertension and anemia. Resident #1's active physician orders as of [DATE] included: - Referral for an endocrinology consultation related to a diagnosis of hypothyroidism. - Draw TSH level every 6 weeks related to hypothyroidism.- Levothyroxine 225 mcg 1 tablet by mouth daily for hypothyroidism at 6:00 AM. A review of Resident #1's [DATE] Medication Administration Record revealed the following medications were prescribed and a review of the medications revealed none interfered with the absorption of Levothyroxine.Amlodipine besylate oral tablet daily for hypertensionTrazodone HCL tablet (antidepressant) for insomniaLevothyroxine 225 mcg for hypothyroidismDepakote Sprinkles oral capsule (antiepileptic) for dementia with behaviors disturbance. Hydroxyzine HCL oral tablet as needed for anxietyOxybutynin chloride tablet for overactive bladder. Myrebetriq for overactive bladder. Losartan potassium for hypertension. Cyanocobalamin tablet for vitamin B12 deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required extensive assistance of one staff member with activities of daily living (ADL). Resident #1's lab results dated [DATE] revealed a TSH level of 50.3. (Previous labs completed on [DATE] resulted in a TSH level of 29.336.) A Nurse Practitioner note written by Nurse Practitioner (NP) #1 dated [DATE] revealed Resident #1 was evaluated on this date. The resident was receiving a dose of (Levothyroxine) thyroid medication at 250 micrograms by mouth daily with a most recent TSH result of greater than 50. The note revealed a referral was initiated for Resident #1 to be evaluated by endocrinology in [DATE]. Resident #1 was noted to have no symptoms of hypothyroidism at the time of the evaluation. Review of Resident #1's Medication Administration Record (MAR) dated [DATE] revealed an order initiated on [DATE] for levothyroxine 225 mcg 1 tablet by mouth daily for hypothyroidism. The medication was administered daily in the AM except on the dates of 6/7 (resident sleeping) and 6/12 (resident sleeping). Further review of the [DATE] MAR revealed no order for levothyroxine 250 mcg. A nursing progress note written by Nurse #2 dated [DATE] at 3:34 PM revealed Resident #1 had eaten 50% or less for 2 or more meals in the day. The note revealed the nursing team had notified the Nurse Practitioner. An interview conducted on [DATE] at 3:03 PM with Nurse #2 revealed she was responsible for Resident #1 on [DATE], [DATE] and [DATE] during the 7:00 AM to 3:00 PM shift and Resident #1 had taken her medication without issues. On [DATE] Resident #1's blood pressure was 150/60 during the morning medication administration pass. She stated Resident #1 hadn't eaten as much for breakfast and lunch on [DATE]. However, she was out of bed and sitting in the common area as she normally did. She stated Resident #1 was confused at baseline, but the Nurse Practitioner was notified any time a resident had a decrease in appetite or seemed more lethargic. Nurse #2 stated Resident #1 did not seem to have an increased sense of thirst nor did anything, stand out. The Nurse Practitioner was in the building, so she saw the resident. She stated she was shocked to learn Resident #1 went to the hospital on [DATE] because she didn't remember the resident having any change of condition in the day's prior. A Nurse Practitioner note written by (NP) #1 dated [DATE] at 8:15 PM revealed Resident #1 was evaluated on this date. The note revealed Resident #1 experienced increased confusion from baseline per nursing staff and a loss in appetite over the last 12 to 24 hours. Resident #1 was noted to have not gotten out of bed as much as she usually did. NP #1's note revealed upon assessment Resident #1 appeared at baseline, was easy to awaken and interacted in conversation. Resident #1 was noted with suprapubic tenderness and an order was given to obtain a urinalysis for further evaluation. A faxed letter was sent to the Endocrinology office for a consultation on [DATE] by Unit Manager #1 for Resident #1. On [DATE] at 1:46 PM an interview was conducted with Unit Manager #1. Unit Manager #1 stated the facility had another Unit Manager that was no longer working in the facility who was responsible for sending Resident #1's endocrinology referral in [DATE]. Unit Manager #1 indicated she became aware of the referral after a Nurse Practitioner note on [DATE] and had seen the physician's order from April was missed. Unit Manager #1 confirmed the first time the referral was sent to the endocrinologist was on [DATE]. Unit Manager #1 stated she felt like the referral was missed by the previous Unit Manager and the mistake had not been identified by any other facility staff members. She stated the typical process was for a Unit Manager to receive a referral for a consultation and then call the physician's office immediately and set up an appointment. The interview revealed typically NP #1 would place her own orders into the electronic medical record (EMR) and the Unit Managers did not always have time to look over NP #1's progress notes. She stated the nursing staff wouldn't have known to increase Resident #1's thyroid medication unless told by NP #1 or the physicians order was placed into the system. Unit Manager #1 stated she did not recall any orders given by Nurse Practitioner #1 after her evaluation of Resident #1 on [DATE]. Unit Manager #1 revealed she had seen Resident #1 in the days prior to [DATE] and she did not recall any changes in the resident's condition. Resident #1 was confused as she typically was, and Unit Manager #1 had seen her attempting to stand up out of her wheelchair which was normal behavior for her. Staff had to keep a close eye on her at all times.An incident report dated [DATE] at 8:30 PM written by Medication Aide (MA) #1 revealed a Nurse Aide (NA #1) reported to MA #1 that Resident #1 had experienced a change of condition. Upon observing Resident #1, MA #1 began to obtain vital signs and told NA #1 to go and notify Nurse #1 of the situation. Nurse #1 applied supplemental oxygen to the resident and called 911 emergency services. On [DATE] at 11:40 AM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she was responsible for Resident #1 on [DATE] during the 3:00 PM to 11:00 PM shift. NA #1 stated when she came on shift at 3:00 PM Resident #1 was her normal self, talking and attempting to get up from her wheelchair as she constantly did. She stated the resident was served the supper meal and was able to feed herself with setup assistance provided. NA #1 stated Resident #1 did not appear to have a decrease in appetite on [DATE]. Around 8:00 PM NA #1 was completing resident charting sitting directly across from Resident #1 approximately 4 feet away. NA #1 stated she looked at Resident #1 and noticed she was mumbling words. She then asked Resident #1 if she was okay and Resident #1 stated, help me. NA #1 stated Resident #1 was alert at that time but seemed weak and began slumping down into her chair. She immediately told MA #1 to obtain vital signs, and she went to get Nurse #1. Nurse #1 went to assess Resident #1 and told them to take her to her room and stay with her while she called 911 emergency services. NA #1 stated EMS was in the building within minutes because they were across the street from the facility. She stated, everyone moved so quickly. The interview revealed once EMS arrived Resident #1 was transported to the hospital for an evaluation. NA #1 indicated she had taken care of Resident #1 in the days prior to the incident and had not noticed any changes in her behavior. On [DATE] at 11:55 AM an interview was conducted with Medication Aide (MA) #1. During the interview she stated she was working on [DATE] during the 3:00 PM to 11:00 PM shift on an adjoining hall to Resident #1's. MA #1 stated she had observed Resident #1 during the shift and saw her eating the supper meal around 5:15 PM with no issues. She stated she was standing at the medication cart in the common area with Resident #1 and NA #1 around 8:00 PM. NA #1 stated to check Resident #1's vital signs because she had just said, help me and went unresponsive. MA #1 then went to the resident and obtained her vital signs while NA #1 went to get Nurse #1. She stated she wrote Resident #1's vital signs down on a piece of paper and gave it to Nurse #1. MA #1 stated Resident #1 was taken to her room and placed in bed while Nurse #1 called 911 emergency services. EMS were in the building within minutes of the staff placing Resident #1 in her bed. MA #1 stated she heard a code blue on the overhead speaker however EMS was already in the building and had assumed care of the resident. She stated Resident #1 still had a pulse and was breathing with supplemental oxygen in place. MA #1 stated she had worked on the days prior to Resident #1 going to the hospital however she was not directly assigned to the resident. MA #1 indicated she had seen Resident #1 eating her meals and she was able to eat the meals without assistance from staff. She stated she did not recall noticing any changes in the resident's behavior prior to [DATE].On [DATE] at 9:57 PM (late entry progress note) a nursing progress note written by Nurse #1 revealed Nurse Aide (NA) #1 had notified her that Resident #1 did not look well and needed to be assessed. NA #1 stated Resident #1 was sitting up in her chair and stated, help me before going unresponsive. Resident #1 did not respond to verbal or tactile (sense of touch) stimulation. Resident #1 was noted to be a full code, her eyes were open, but she was breathing shallow. The resident's vital signs were the following: temperature 97.1, pulse 67, respirations 8, oxygen saturation 88% on room air with a blood pressure reading of 105/76. A call was placed to 911 emergency services, and the resident was provided with supplemental oxygen at 2 liters per minute via nasal cannula. The 911 dispatcher advised Nurse #1 to prepare for Cardiopulmonary Resuscitation (CPR) and a code blue was paged overhead for staff to hear. Emergency Medical Services (EMS) was able to arrive quickly at the facility and already were entering Resident #1's room. EMS decided that CPR was not needed, and Resident #1 was transported to the hospital for further evaluation at 8:30 PM. On [DATE] at 3:45 PM an interview was conducted with Nurse #1. Nurse #1 stated she was responsible for Resident #1 on [DATE] during the 3:00 PM to 11:00 PM shift. She stated when she came on shift at 3:00 PM she saw Resident #1 sitting in her chair in the common area watching television. Resident #1 was her typical self, talking and attempting to stand up during the shift like she normally did. Nurse #1 stated Resident #1 was served her supper meal around 5:30 PM. Resident #1 was able to feed herself without assistance from staff members. During the gathering of meal trays, Resident #1 was observed to be alert, sitting watching television and interacting with other residents in the common area. Nurse #1 was notified by NA #1 around 7:50/8:00 PM that Resident #1 had experienced a change of condition. She stated the resident looked at NA #1 and said, help me before becoming unresponsive. Nurse #1 immediately went to the resident to assess her vital signs. MA #1 and NA #1 assisted Resident #1 to her room and into bed. Nurse #1 called 911 emergency services, and they advised her to prepare to perform CPR however Resident #1 still had a pulse and was breathing at that time. Nurse #1 stated EMS arrived quickly because they were right across the street. EMS took over the care of Resident #1, stabilized the resident and transported her to the hospital for an evaluation. When she was transported out of the facility, Resident #1 was alert and talking again. Nurse #1 stated she had seen no change in Resident #1's behavior throughout the shift until NA #1 alerted her to a change of condition. She also stated she had cared for Resident #1 in the days prior to the incident and had seen no overall change in the resident's condition. The interview revealed she did not remember Resident #1 having any increased confusion nor had nurse aides notified her the resident had a decrease in appetite. Emergency Medical Service (EMS) records dated [DATE] at 8:02 PM revealed Resident #1 was lying on her bed in the facility unresponsive. Staff members from the facility were standing at the doorway stating the resident was okay ten minutes prior to calling 911. Resident #1's heart rate was 32 beats per minute (bpm) and a transcutaneous pacemaker (temporary external pacing method used to stimulate the heart to contract by delivering electrical impulses through the chest wall) was placed on Resident #1 by EMS. An improvement in heart rate was noted with a reading of 82 bpm (beats per minute). During transportation to the hospital Resident #1's heart rate began to drop with a reading of 44 bpm. EMS was able to increase the residents heart rate back up to 62 bpm while en route to the hospital. Upon arrival at the hospital Resident #1 was moved from the EMS stretcher to an Emergency Department (ED) bed and hospital staff assumed care for the resident. During the transfer of the beds Resident #1 was noted to decline rapidly without a pulse. The ED initiated CPR and Resident #1 was ultimately intubated in the ED by hospital staff. Emergency Department records dated [DATE] at 8:34 PM revealed Resident #1 was found in an unresponsive state at the nursing facility. Resident #1 had arrived at the ED unresponsive with a transcutaneous pacemaker in place. Upon assessment by the ED Physician Resident #1 was noted to have a pulse oximetry (measures the percentage of oxygen in the blood) of 7% (normal level 95-100%). CPR was initiated for a duration of 2 minutes. An emergent intubation was required, and Resident #1 was placed on a ventilator. Resident #1 was noted to be in a severe hypothyroid state with a diagnosis of myxedema coma (a life-threatening endocrine emergency that occurs when thyroid hormone regulation is disrupted) and a TSH level of 240. The resident received 200 mcg of Levothyroxine intravenously in the ED. Resident #1 was admitted into the hospital intensive care unit with diagnosis of bradycardia (low heart rate), respiratory arrest, myxedema coma and cardiac arrest with profound hypothyroidism contributing to the diagnosis. Hospital records dated [DATE] revealed Resident #1 was intubated in the ED and noted to be hypothermic (low body temperature) with a lowest temperature of 91.1 degrees Fahrenheit (normal body temperature 98.6). Resident #1's TSH level was 242.997. She was admitted into the ICU with continued intubation and ventilation. The primary admission diagnosis was myxedema coma followed by bradycardia, unresponsiveness and hypothermia. The hospitalist consulted with endocrinology; Resident #1 received a loading dose of levothyroxine (thyroid medication) 375 mcg intravenous on [DATE]. It was recommended she continue to receive 100mcg levothyroxine daily. Resident #1 was extubated on [DATE] and was still in the hospital setting during the survey period receiving occupational therapy, physical therapy, speech therapy and hospitalist services. On [DATE] at 9:11 AM and 3:51 PM an interview was attempted with a Hospitalist. No phone call was returned to the surveyor. On [DATE] at 8:49 AM the Director of Nursing (DON) from the Hospital called and stated the surveyor would need to submit a formal request for an interview with the Hospitalist. On [DATE] at 10:05 AM a formal request was submitted and faxed by the Department of Health and Human Services Division of Health Service Regulation for an interview with the Hospitalist. No return phone call was received. An interview conducted on [DATE] at 9:45 AM with Family Member #1 revealed she was notified on [DATE] Resident #1 was found in an unresponsive state and sent to the hospital for an evaluation. She stated Resident #1 was still in the hospital, was drowsy but doing better. Family Member #1 stated she felt the facility was not giving the residents medication correctly for her thyroid level to be so high on the paperwork from the hospital. She stated she had visited in the weeks prior to the incident on [DATE] and hadn't noticed a change in Resident #1's behavior but had not visited on [DATE]. Family Member #1 indicated Resident #1 had not reported that she was not feeling well. On [DATE] at 1:58 PM an interview was conducted with the Director of Nursing (DON). The DON stated she was in the facility on the night of [DATE] but did not see Resident #1 until she was being taken out of the front hall by EMS. The interview revealed Resident #1 had a diagnosis of hypothyroidism and was followed by Nurse Practitioner #1 and the Medical Director. The DON indicated Nurse Practitioner #1 had put in an order on [DATE] for an endocrinology consult due to the resident's elevated TSH level and the Unit Manager at the time did not complete the referral. This was not identified until [DATE] by Unit Manager #1 and Unit Manager #1 then faxed the referral over to the endocrinology office. However, an appointment was never made because when the endocrinology office called the facility back the resident was already at the hospital. She stated the original endocrinology consult should have been completed within a week when it was received back in [DATE]. She stated while reviewing paperwork during the survey she realized Nurse Practitioner #1 had put in her progress note dated [DATE] to increase Resident #1's thyroid medication to 250 mcg by mouth daily for hypothyroidism. The DON stated NP #1 would typically, 99% of the time put her own orders into the electronic medical record (EMR). She stated NP #1 should have put the physicians' order into the EMR or told a nursing staff member to put the order in so it could have been relayed to the MAR. The DON confirmed Resident #1's thyroid medication had not been increased to 250 mcg during the months of [DATE] and [DATE] prior to her hospitalization. Nurse Practitioner #1 was unable to be interviewed during the survey due to a medical emergency. On [DATE] at 12:40 PM an interview was conducted with the Medical Director. The Medical Director stated the resident was admitted into the facility with a diagnosis of hypothyroidism in [DATE]. The facility had closely monitored Resident #1's thyroid level and adjusted her medication accordingly. An order for an endocrinology consult was made in [DATE] by Nurse Practitioner #1 being proactive in the resident's care since she had an elevated TSH level. The Medical Director indicated he had seen NP #1's progress note dated [DATE] to increase her thyroid medication dosage. The Medical Director stated it was a common error, NP #1 forgot to write the order for the increased medication. The Medical Director stated increasing Resident #1's thyroid medication wouldn't have made a difference in the outcome of her TSH level. The Medical Director stated NP #1 was handling Resident #1's care appropriately and had been monitoring her lab work closely since admission and adjusted her thyroid medication throughout the past year. He did not recall NP #1 contacting him regarding Resident #1's TSH level of 50.3 on [DATE]. The Medical Director further stated he felt like the diagnosis of myxedema coma was due to the hospital assuming the resident's thyroid levels were not being monitored or treated, and they had a mistaken impression because the resident was lethargic with a TSH of 240 and jumped to conclusions.On [DATE] at 4:00 PM an interview was conducted with the Administrator. He stated the facility should have completed the endocrinology consultation in a timely manner. The Administrator indicated there had been a gap in Unit Managers and the consultation order had just been missed by nursing staff. The Administrator further stated the physician order for the [thyroid] medication increase was missed and should have been in the EMR and Resident #1's medication should have been increased if ordered by the physician. The Administrator was notified of the immediate jeopardy on [DATE] at 11:46 AM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncomplianceThe facility failed to provide effective medical evaluation and treatment to Resident #1. Resident #1 had labs completed on [DATE] resulting in a thyroid stimulating hormone (TSH) level of 29.336. The Nurse Practitioner wrote an order for an Endocrinology Consultation on [DATE]. Resident #1 did not have an endocrinology appointment scheduled. Resident #1 had labs completed on [DATE] for a T4 lab, with results of 3.8 (normal 4.5-12.0), Free T3 results 1.59 (normal 1.58-3.9. The Nurse Practitioner saw Resident #1 on [DATE] and increased Resident #1's medication from 225 micrograms (mcg) to 250 mcg by mouth daily, which was in the Nurse Practitioner Progress Note, but was not entered into Resident #1's electronic medical record as an order at the time by the Nurse Practitioner, so therefore Resident #1 did not have the recommended increase in the thyroid medication from 225mcg to 250mcg implemented on [DATE] on the Medication Administration Record (MAR). Resident #1 remained on 225mcg of thyroid medication from [DATE] to [DATE]. Resident #1's TSH level on [DATE] was 50.3, which was not addressed at that time. The Nurse Manager faxed the order to schedule the Endocrinology Consultation on [DATE]. On [DATE], the Director of Nursing reviewed the electronic medical record of current residents to determine those on thyroid medications. Based on the list, the Director of Nursing identified 6 other residents receiving thyroid medication. The Director of Nursing reviewed the Nurse Practitioner's most recent progress notes for these 6 residents to ensure their current orders for thyroid medication corresponded to the dose which was indicated in the progress notes and that the medication orders are accurately transcribed to the Medication Administration Record (MAR).Current residents on thyroid medications had their most recent TSH lab results that were completed in the past 120 days reviewed by the Medical Director on [DATE] and [DATE] to ensure the thyroid medication doses are effective. Current residents' orders for the past 30 days were reviewed by the Director of Nursing (DON) /Assistant Director of Nursing (ADON) on [DATE] to ensure that orders for consultations to include endocrinology have been carried out or are scheduled for a consultation at a future date.Medical Doctor/Nurse Practitioner notes for recommendations for consultations were reviewed for the past 30 days on [DATE] by the DON/ADON to ensure any recommendations had been carried out. On [DATE], current residents on thyroid medications and/or upcoming endocrinology appointments, per the electronic medical record order listing report, had a head-to- toe physical assessment by the Assistant Director of Nursing who is a Registered Nurse, as well as a focused based physical examination by the Nurse practitioner, which included vital signs to ensure their vital signs were stable and they were not experiencing a change in condition to include signs and symptoms of hypothyroidism (fatigue, cold sensitivity, constipation, dry skin, and unexplained weight gain) and hyperthyroidism (weight loss, rapid or irregular heartbeat, sweating, and irritability) which would require further medical intervention or a transfer to a higher level of care, and no other residents were identified. On [DATE], the Director of Nursing (DON) and Assistant Director of Nursing (ADON) reviewed the last 90 days of the Pharmacy recommendations to ensure residents receiving thyroid medications did not have any outstanding recommendations that needed to be implemented. No concerns were identified.On [DATE], the Pharmacist reviewed the 6 residents on thyroid medication to ensure no drug to drug interactions with medications that would be taken at or around the same time of the thyroid medication or that could affect absorption of the medication. The Pharmacist additionally reviewed the 6 residents to ensure the thyroid medication is scheduled to be given at the proper time of 6 am daily. Last, the Pharmacist reviewed the 6 residents to ensure current lab orders are in place to monitor thyroid drug therapy. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completeThe Nurse Practitioner was re-educated by the Medical Director on [DATE] on ensuring any medication orders which the Nurse Practitioner orders while making rounds in the facility are entered into each resident's individual electronic medical record by the Nurse Practitioner and should correspond with the Nurse Practitioner progress notes. The DON and ADON were educated on [DATE] by the Regional Clinical Director that a review of Medical Provider progress notes will be done daily by the DON/ADON during morning clinical meeting to ensure the Medical Provider's progress notes that make mention of medication changes correspond to the residents' current medication orders that have been input into the electronic medical record. The Nurse Practitioner was educated on [DATE] by the Medical Director to obtain thyroid panel labs at least every 3-6 months for monitoring of those residents on thyroid medications. Abnormal lab results will be addressed by the Medical Provider including the Medical Director/ Nurse Practitioner to ensure a comprehensive plan for treatment which may include but not be limited to physical assessment of the resident for signs and symptoms of hypothyroidism or hyperthyroidism, further lab monitoring, increases/decreases in medication regimen, consultation with endocrinology specialist, or transfer to a higher level of care. Licensed nursing staff have been educated by the Director of Nursing/Assistant Director of Nursing on [DATE] and [DATE] on the following: - ensuring thyroid medication orders are entered accurately, at the time recommended by the physician and the pharmacy/ or procedure which is at 6 am on an empty stomach, given with water, and if crushed then it can be given with a small amount of applesauce or pudding- to avoid drinks that could interact with the medication which would be caffeinated drinks such as coffee, tea, fizzy drinks and calcium containing drinks such as milk, fruit juices should not be consumed until 30-60 minutes after receiving thyroid medications- when taking thyroid medication, you must wait 30-60 minutes before eating - medications that have the potential to reduce adsorption for thyroid medication are antacids, Carafate, cholestyramine, colestipol, phosphate binders, and some antibiotics, as well as calcium and iron supplements. - recognizing changes in condition along with notification to the medical provider to include identification of and notification of signs and symptoms of hypothyroidism (fatigue, cold sensitivity, constipation, dry skin, and unexplained weight gain) and hyperthyroidism (weight loss, rapid or irregular heartbeat, sweating, and irritability), this education also included monitoring every shift for signs and symptoms of hypothyroidism and hyperthyroidism and to notify the provider accordingly upon identification of any signs or symptoms- notification of abnormal TSH lab results to ensure notification to the Physician/Nurse Practitioner- the signs and symptoms of hypothyroidism and hyperthyroidism have been added to the Medication Administration Record by the Director of Nursing/Assistant Director of Nursing on [DATE]. Any Licensed Nurses not educated by [DATE] will be educated prior to the start of their next scheduled shift. This education will be provided by the Director of Nursing/Assistant Director of Nursing. On [DATE] and [DATE] The Director of Nursing/Assistance Director of Nursing educated all Certified Nursing Assistance (CNAs) on notification to Licensed Nurses on any changes in condition. Any Certified Nursing Assistance (CNAs) that were not educated on [DATE] will be educated prior to the start of their next scheduled shift which will be provided by the Director of Nursing/Assistant Director of Nursing.The DON/ADON reviewed the facility's process for carrying out consultation orders on [DATE]. No changes were required.Licensed Nurses/Unit Managers were educated on the process for consultation orders on [DATE] and [DATE] by the Director of Nursing and Assistant Director of Nursing to include the process for carrying out consultation orders:- At the time that the order is written for consultation in the electronic medical record eit[TRUNCATED]

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge status (Resident #98), Preadmission Screening and Resident Review (PASRR) (Resident #76), falls (Resident #54), and physical restraints (Resident #73). This deficient practice occurred for 4 of 19 residents reviewed for accuracy of assessments. The findings included: 1. Resident #98 was admitted to the facility 6/15/23 and discharged from the facility 4/10/25. The facility discharge summary dated 4/10/25 revealed Resident #98 was discharged to an Assisted Living Facility (ALF). The discharge MDS assessment dated [DATE] indicated Resident #98's discharge was unplanned, initiated by the facility and return was not anticipated. Resident #98's discharge location was coded short-term hospital. During an interview with MDS Coordinator #1 on 5/21/25 at 3:46 PM he revealed when a resident was discharged from the facility, he reviewed the electronic medical record and/or communicated with staff to determine the resident's discharge location prior to completing the MDS. He stated Resident #98 was discharged to an ALF on 4/10/25. MDS Coordinator #1 indicated Resident #98's discharge location coded short term hospital was inaccurate and an oversight on his part. An interview with the Director of Nursing on 5/22/25 at 3:59 PM indicated Resident #98 was discharged to an ALF and the MDS assessment should have been coded with an accurate discharge location. An interview conducted with the Administrator on 5/22/25 at 4:24 PM revealed resident MDS assessments should be coded accurately. 40476 2. Resident #76 was admitted to the facility on [DATE] with diagnoses which included schizophrenia. A Pre-Admission Screening and Resident Review (PASRR) dated 05/24/24 revealed Resident #76 was determined to be a level II PASRR (a person having or suspected of having a PASRR condition such as serious mental illness, intellectual disability or developmental disability). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #76 revealed she was moderately cognitively impaired. Under the section for PASRR Resident #76 was coded as not being a level II. An interview conducted on 05/22/25 at 12:12 PM with MDS Coordinator #1 at the facility revealed he had just started at the facility in April of 2025 and was not at the facility when the annual MDS was completed. MDS Coordinator #1 stated the resident was a level II PASRR and should have been coded for it on the MDS assessment. MDS Coordinator #1 further stated he would modify the assessment and resubmit. An interview on 05/22/25 at 12:25 PM with the Director of Nursing revealed she expected MDS assessments to be coded correctly to reflect the individual resident. An interview on 05/22/25 at 1:54 PM with the Administrator revealed he expected all MDS assessments to be coded correctly to reflect the residents' conditions. 3. Resident #54 was admitted to the facility on [DATE] with diagnoses which included orthostatic hypotension. An incident report dated 12/29/24 at 10:31 PM revealed Resident #54 had experienced an unwitnessed fall and was found sitting on the floor in her room yelling for help. No injuries were noted at the time of the fall. An incident report dated 03/18/25 at 12:30 AM revealed Resident #54 had experienced a witnessed fall in her room by nursing staff. No injuries were noted at the time of the fall. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed she was severely cognitively impaired. Under the section for fall history since admission, entry or reentry Resident #54 was coded as having experienced no falls since admission into the facility. An interview conducted on 05/22/25 at 12:12 PM with MDS Coordinator #1 at the facility revealed he had just started at the facility in April of 2025. MDS Coordinator #1 stated looking back at Resident #54's nursing progress notes she had experienced several falls and should have been coded for it on the MDS assessment. MDS Coordinator #1 further stated he would modify the assessment and resubmit. An interview on 05/22/25 at 12:25 PM with the Director of Nursing revealed she expected MDS assessments to be coded correctly to reflect the individual resident. An interview on 05/22/25 at 1:54 PM with the Administrator revealed he expected all MDS assessments to be coded correctly to reflect the residents' conditions. 4. Resident #73 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident (CVA). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #73 revealed he was unable to complete the cognition portion of the assessment. Under the section for physical restraints, Resident #73 was coded for use of bed rails. Resident #73 was observed on 05/19/25 at 11:13 AM lying in bed. No bed rails were observed on Resident #73's bed. Resident #73 was observed on 05/21/25 at 10:42 AM lying in bed. No bed rails were observed on Resident #73's bed. An interview conducted on 05/22/25 at 12:12 PM with MDS Coordinator #1 at the facility revealed he had just started at the facility in April of 2025 and was not responsible for completing the MDS assessment. MDS Coordinator #1 stated the facility was restraint free, and that no residents currently residing in the facility used bed rails. He stated the MDS was coded inaccurately. MDS Coordinator #1 further stated he would modify the assessment and resubmit. An interview on 05/22/25 at 12:25 PM with the Director of Nursing revealed she expected MDS assessments to be coded correctly to reflect the individual resident. An interview on 05/22/25 at 1:54 PM with the Administrator revealed he expected all MDS assessments to be coded correctly to reflect the residents' conditions.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan in the area of colostomy care for 1 of 1 resident reviewed for colostomy care (Resident #35). The findings included: Resident #35 was admitted to the facility 4/13/22 with diagnoses that included colostomy status. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 was coded for having a colostomy. Resident #35's comprehensive care plan dated 2/18/25 revealed no problem areas or interventions related to colostomy care. During an interview with MDS Coordinator #2 on 5/21/25 at 4:00 PM she stated there were no interventions related to colostomy care in Resident #35's care plan which was an oversight on her part. An interview conducted with the Director of Nursing (DON) on 5/22/25 at 3:59 PM revealed Resident #35's colostomy status was a significant part of her care and should have been included in the comprehensive care plan. An interview with the Administrator on 5/22/25 at 4:24 PM indicated that goals and interventions related to colostomy care should be included in the resident's comprehensive care plan.

Based on observation, record review, resident, and staff interviews, the facility failed to apply a right-hand splint for 1 of 3 sampled residents reviewed for limited range of motion (Resident #73). Findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA). An active physician order originally dated 11/16/23 revealed a right resting hand splint, on after AM care and off after PM care daily. A review of Resident #73's medical record revealed an Occupational Therapy (OT) discharge summary dated 12/20/2024 indicated Resident #73 had a diagnosis of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis) following a cerebral infarction affecting the right dominant side. A splint program was established. Resident #73 had been agreeable to donning splint and self-doffs the splint 1-2 hours later. The summary stated Resident #73 should be wearing the right resting hand splint for up to 8 hours/day. OT completed staff/caregiver education for splinting program with appropriate staff/caregivers and would then transition into the splinting program due to no further need for OT to address. Resident #73's quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the resident as unable to complete the cognition portion of the assessment. He was coded as needing limited assistance of one staff member for toileting and transfers. His functional limitation in range of motion indicated he had no impairment to his upper extremity and lower extremity. A review of the May 2025 Medication Administration Record revealed documentation of Resident #73's right hand splint being on every AM from 5/1/25 through 5/21/25. Further review revealed the right-hand splint was documented as being on every AM shift on 05/19, 05/20 and 05/21 by Nurse #1. Resident #73 was observed on 05/19/25 at 11:13 AM without a splint to the right hand and the right hand was noted to be flaccid (limp and lacking voluntary movement). During the observation and interview, Resident #73 was observed to be lifting up his right arm and dropping it onto his bed. Resident #73 was observed to be pointing to his right hand to alert the surveyor that there was an issue. Resident #73 was unable to communicate verbally with the surveyor however was able to answer by giving a thumbs up for yes and a thumbs down for no. When asked the question, do the staff apply the hand splint, Resident #73 gave a thumbs down for no. The surveyor then asked if Resident #73 could apply the hand splint himself and he gave a thumbs down for no. The right-hand splint was not observed to be in Resident #73's room. Resident #73 was observed on 05/21/25 at 10:42 AM lying in bed. During the observation, Resident #73 was observed to be lifting up his right arm and dropping it onto his bed. Resident #73 was observed on 05/21/25 at 2:25 PM sitting in his wheelchair in the resident common area. The right-hand splint was not observed on Resident #73's hand. An interview conducted on 05/21/25 at 2:25 PM with Nurse Aide #1 revealed she hadn't seen Resident #73s right hand splint for several weeks. NA #1 stated she hadn't seen it placed on his right hand for over a month. She stated she thought therapy staff applied the residents splint and not nursing staff. The interview revealed she had not received education on applying the splint to Resident #73's right hand nor was told to. An interview conducted on 05/21/25 at 2:35 PM with Nurse #1 revealed she thought Resident #73 had a right-hand splint but that he removed it himself. She stated she would sometimes observe it when she went into the room to administer his medication, and that Therapy staff were good about applying it in the mornings after AM care. She stated in particular on 05/21/25 that she did not apply Resident #73's right hand splint because she thought therapy services were applying it. An interview conducted on 05/21/25 at 10:50 AM with the Therapy Director revealed Resident #73 was discharged from therapy services on 03/22/25. She stated the last time Resident #73 was evaluated for his right-hand splint was 12/20/24 in which they recommended the right-hand splint with a goal of 6-8 hours wearing the splint. She stated Resident #73 could remove the splint himself after it was applied. She stated the nursing staff were responsible for putting the right-hand splint on the resident and would have been provided education in December based on the Physical Therapy discharge summary. The Therapy Director indicated she had just evaluated Resident #73 prior to the interview and Resident #73's right hand mobility had not gotten worse since the last evaluation on 12/20/24 and he had not developed any skin breakdown or new injury to the right-hand. An interview was conducted on 05/22/25 at 12:25 PM with the Director of Nursing (DON). The DON stated Resident #73's splint should have been applied as indicated in the physician's orders. The DON stated it was her expectation for nursing assistants to apply the splint and if they had any difficulties then they should have informed their supervising nurse. An interview conducted on 05/22/25 at 1:54 PM with the Administrator revealed the nursing staff should have applied the splint as indicated.

Based on record review and staff interviews, the facility failed to ensure a medical record was accurate regarding the Medication Administration Record (MAR). This was for 1 of 1 resident in the area of right-hand splint application (Resident #73) and 1 of 1 resident in the area of medication administration (Resident #69) who were reviewed for medical record accuracy. Findings included: A review of the May 2025 Medication Administration Record revealed documentation of Resident #73's right hand splint being on every AM from 5/1/25 through 5/21/25. Further review revealed the right-hand splint was documented as being on every AM shift on 05/19, 05/20 and 05/21 by Nurse #1. Resident #73 was observed on 05/19/25 at 11:13 AM without a splint to the right hand and the right hand was noted to be flaccid (limp and lacking voluntary movement). During the observation and interview, Resident #73 was observed to be lifting up his right arm and dropping it onto his bed. Resident #73 was observed to be pointing to his right hand to alert the surveyor that there was an issue. Resident #73 was unable to communicate verbally with the surveyor, however, was able to answer by giving a thumbs up for yes and a thumbs down for no. When asked the question, do the staff apply the hand splint, Resident #73 gave a thumbs down for no. The surveyor then asked if Resident #73 could apply the hand splint himself and he gave a thumbs down for no. The right-hand splint was not observed to be in Resident #73's room. Resident #73 was observed on 05/21/25 at 10:42 AM lying in bed. During the observation, Resident #73 was observed to be lifting up his right arm and dropping it onto his bed. The right-hand splint was not observed on Resident #73's hand. Resident #73 was observed on 05/21/25 at 2:25 PM sitting in his wheelchair in the resident common area. The right-hand splint was not observed on Resident #73's hand. An interview conducted on 05/21/25 at 2:25 PM with Nurse Aide #1 revealed she worked with Resident #73 on a regular basis. She stated she hadn't seen Resident #73s right hand splint for several weeks. NA #1 stated she hadn't seen it placed on his right hand for over a month. An interview conducted on 05/21/25 at 2:35 PM with Nurse #1 revealed she thought Resident #73 had a right-hand splint but that he removed it himself. She stated she would sometimes observe it when she went into the room to administer his medication, and that Therapy staff were good about applying it in the mornings after AM care. She stated in particular on 05/21/25 that she did not apply Resident #73's right hand splint because she thought therapy services were applying it. She stated that was why she documented the right hand splint was on. An interview was conducted on 05/22/25 at 12:25 PM with the Director of Nursing (DON). The DON stated Resident #73's splint should have been applied as indicated in the physician's orders. The DON stated it was her expectation for nursing staff to be accurately document on the MAR. An interview conducted on 05/22/25 at 1:54 PM with the Administrator revealed the nursing staff should have accurately documented in the medical record. 51667 2. Resident #69 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact. A review of current physician order for Resident #69 dated 6/28/2024 revealed to administer Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP. Give 17 grams orally as needed for constipation, mixed with 4 to 8 ounces liquid of choice. Daily as needed. Record review revealed progress note dated 5/2/2025 entered by Nurse #3. According to the note, Resident #69 had not had a bowel movement in 3 days and was given constipation medication on 5/2/25. A review of Resident #69's Medication Administration Record (MAR) for May 2025 revealed Nurse #3 did not document the administration of Polyethylene Glycol 3350 oral power in the month of May 2025. The phone interview on 05/22/25 at 3:43 PM with Nurse #3 revealed she was assigned to review bowel records and report negative findings to providers. Nurse #3 stated she did not remember progress note dated 5/2/25 for Resident #69. Nurse #3 reported that she remembered that Resident #69 had gone 3 days without bowel movement according to bowel records and gave Resident #69 whatever the provider ordered for constipation. Nurse #3 stated that she would document bowel interventions in the bowel record that was then linked to progress notes. Nurse #3 stated she would have documented any medication given to Resident #3 on his MAR. Nurse #3 stated she had forgotten to chart the medication for the bowel intervention. The Director of Nursing (DON) was interviewed on 05/22/25 at 04:06 PM. The DON reported Nurse #3 was assigned to review bowel records and work with the providers for bowel interventions for the residents. The DON stated that Nurse #3 should document bowel medications given to the residents in their MAR. The Administrator was interviewed on 05/22/25 at 01:55 PM. The Administrator reported the nurses were expected to document any medication provided to the residents in the residents' MAR. The Administrated stated, If it was not documented it was not done.

Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Unit Manager did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #7. This deficient practice occurred for 1 of 4 staff members observed for infection control practices (Unit Manager). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: a. Immediately before touching a resident. b. Before performing an aseptic task c. After contact with blood, body fluids, or contaminated surfaces. d. After touching a resident e. After touching the resident's environment f. Before moving from working on a soiled body site to a clean body site on the same resident; and g. Immediately after glove removal. A wound care observation was made on 05/22/25 at 9:13 AM on Resident #7 with the Unit Manager. The Unit Manager was observed cleaning the bedside table with disinfectant wipe and placed her wound supplies on the table after it dried. Unit Manager #1 donned a clean gown and clean gloves. She then removed the old dressing from the resident's sacrum and placed the soiled dressing onto the clean bedside table. She then proceeded to clean the area around the wound with a wound care solution and dry the area with gauze. The Unit Manager doffed her gloves and without sanitizing her hands, donned clean gloves and applied a collagen sheet with a dry dressing to Resident #7's wound. Using the same gloves the Unit Manager was observed assisting Resident #7's brief back on and lower the residents bed to a downward position. She then doffed her gown, washed her hands with soap and water, collected her supplies, wiped down the table and left the resident's room. An interview conducted on 05/22/25 at 2:10 PM with the Unit Manager revealed she was aware that she had not sanitized her hands each time she had doffed her gloves. She stated she typically did not complete the dressing changes in the facility. However, the Wound Nurse had quit a couple of days before, so she was asked to perform wound care for the day. The Unit Manager stated she immediately realized she had not performed hand hygiene after the observation was made and knew she should have sanitized her hands in between or went into the resident's bathroom to wash her hands with soap and water. The Unit Manager also stated she should have placed the soiled dressing into the trash can instead of placing it onto the clean bedside table with the wound care supplies. An interview conducted on 05/22/25 at 10:57 AM with the Infection Preventionist (IP) revealed she was not aware of the errors made by the Unit Manager during wound care. She stated her expectation was that she would sanitize her hands every time that she removed her gloves and before putting on clean gloves during wound care. The IP further stated staff received education on infection control annually and multiple times during the year. An interview on 05/22/25 at 12:25 PM with the Director of Nursing (DON) revealed she was aware of the Unit Manager's errors during wound care and said she had been provided with additional education regarding doffing and donning and sanitizing in between glove changes. The DON stated it was her expectation that the Unit Manager followed infection control best practices to avoid introducing microorganisms into the wounds. She further stated the facility typically had a Wound Care Nurse however, she had left that same week, and the Unit Manager was asked to perform the dressing change for the day. An interview on 05/22/25 at 1:54 PM with the Administrator revealed he would expect the Unit Manager to follow the Hand Hygiene policy for wound care.

Based on record review and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in writing of the resident's transfer and discharge to the hospital for 1of 2 residents reviewed for hospitalization (Resident #150). The findings included: Resident was admitted to the facility on [DATE]. A nursing note dated 4/13/2025 at 6:51 PM stated Resident #150 was transferred to the hospital for further workup of lack of appetite and generalized weakness. A nursing note dated 4/18/2025 at 2:37 PM indicated Resident #150 was readmitted to the facility. A nursing note dated 4/28/2025 at 6:26 PM stated Resident #150 was transferred to the hospital due to urinary retention. A nursing note dated 5/15/2025 at 4:15 PM indicated Resident #150 was readmitted to the facility. An interview on 5/22/2025 at 11:38 AM with the Ombudsman revealed she did not receive a hospital transfer and discharge list for April 2025. An interview on 5/22/2025 at 9:36 AM with the Director of Nursing (DON) indicated that Resident #150 had been transferred to the hospital several times since her admission to the facility. She indicated social work was responsible for communicating information to the Ombudsman regarding hospital transfers and discharges. An interview on 5/22/2025 at 11:56 AM with Social Worker (SW) #1 revealed she was unaware that information regarding hospital transfers and discharges was to be provided to the Ombudsman. SW #1 indicated this requirement had never been mentioned to her during her training. She stated she had not sent any transfer or discharge lists to the Ombudsman since the start of her employment in February 2025. She stated no one at the facility was currently sending the transfer/discharge list to the Ombudsman. An interview on 5/22/2025 at 1:11 PM with the Administrator revealed that the SW was responsible for notifying the Ombudsman of hospital transfers and discharges. He stated he had become aware today that social work had not been providing the hospital transfer and discharge list to the Ombudsman. He did not understand how this requirement had been missed as he had sent SW #1 to other nursing facilities to train with other social workers. The Administrator stated the hospital transfer and discharge list should be sent to the Ombudsman each month.

Based on record review and interviews with staff, Resident, Nurse Practitioner (NP) #2, NP #3 and Medical Director (MD), the facility failed to immediately consult with NP #3, the on-call medical provider, when Resident #49 who had a pre-existing traumatic brain injury lost consciousness and was slumped in his chair after being hit on the back of his head by Resident #79, his roommate. On 09/14/24 at 9:05 AM Nurse #3 heard a loud hit or thud coming from across the unit. She noted Resident #49 was in his wheelchair rolling out from his room and witnessed Resident #79 swing his arm with a fist and hit Resident #49 on the back of the head. NP #3 was notified after the incident occurred about an altercation between Resident #49 and Resident #79 but was not consulted about the blow to Resident #49's head, the slumping in the chair and the loss of consciousness for a few seconds. Resident #49 had a change of condition after the altercation occurred. He slid out of his wheelchair. His level of assistance needed for transfer and bed mobility changed and he was confused. Later in the day and as his condition continued to decline, staff assessed Resident #49 with altered mental status (AMS) and he was sent to the hospital for evaluation due to a concern for a concussion after a fall. The deficient practice affected 1 of 3 residents reviewed for physician notification (Residents #49). Immediate jeopardy began on Saturday, 09/14/24, when the facility failed to immediately consult with NP #3 about Resident #49 who had a pre-existing traumatic brain injury and had a significant change in condition following a blow to the head with a brief loss of consciousness. The immediate jeopardy was removed on 11/23/24 when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #49 was admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI). A review of Resident #49's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #49 was coded as independent for eating and putting on/ taking off footwear. He required set up or clean up assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #49 required supervision assistance for chair to bed transfers, toileting transfers, tub/shower transfers and lying to sitting on the side of the bed. The resident was noted to be independent for rolling left and right while in bed. Resident #49 was continent of bowel and bladder during the assessment period and was documented to have no behaviors. A nursing note written by Nurse #3 dated 09/14/24 at 10:11 AM revealed she heard hitting noises and turned around to observe Resident #79 hit Resident #49 get hit in the head. The note revealed the residents were separated and assessed for injuries. Resident #49's vital signs were the following: blood pressure 138/66; pulse 72; temperature 97.9; respirations 20; and oxygen saturation level 96% on room air. The Resident was noted with no signs of acute distress at the time of the incident and no complaints of pain. Redness was noted to the back of the Resident's neck. The Resident's Responsible Party, Director of Nursing and on call Nurse Practitioner (NP #3) were notified about the abuse and the Resident's status. On 11/19/24 at 11:38 AM an interview was conducted with Nurse #3. Nurse #3 stated on 09/14/24 around 9:00 AM she heard a loud hit or thud coming from across the unit. She then saw Resident #49 rolling out from his room in his wheelchair and witnessed, Resident #79 swinging his arm with a fist and hit Resident #49 in the back of the head making a second thud sound as his fist hit the back of Resident #49's head. Resident #49 immediately slumped over in his wheelchair as a result of the incident. Nurse #3 stated Resident #49 regained consciousness within a couple of seconds after she got to him to assess his condition. She stated she saw redness at the back of Resident #49's head and neck area. When Resident #49 came to he asked to go outside to smoke so NA #2 took him to the smoking area. Nurse #3 indicated she had obtained initial vital signs on Resident #49 which were within normal range, assessed him. Nurse #3 stated she did not recall reporting the loss of consciousness and slumping in the chair to Unit Manager #1. Nurse #3 explained Resident #49 was moved from his hall around 10:00 AM. Nurse #3 no longer was his nurse and did not see him again that day. The interview revealed Nurse #3 had initiated an action rounding log which documented where Resident #49 was in the facility every 15 minutes. Nurse #3 stated Nurse #4 took over Resident #49's care when he moved to his new room around 10:00 AM. On 11/21/24 at 12:32 PM an interview was conducted with Scheduler #1. She stated she was working as the Manager on Duty on 09/14/24. Scheduler #1 stated her office door was open and she overheard a nurse screaming for help. When she went out into the hall, she saw Nurse #3 in the hall and went to her. She noticed Resident #49 sitting in his wheelchair slumped over around 9:00 AM. Nurse #3 explained to her that he had just been hit in the back of the head by his roommate. After separating the residents, she stated she notified Unit Manager #1 via the facility paging system and Nurse #3 called the Director of Nursing. Scheduler #1 stated Resident #49 was taken to the smoking area because he stated he wanted to go smoke however she stated she did not see him smoking. She stated Resident #49 immediately seemed spaced out and not to be thinking clearly when he went to the smoking area around 9:30 AM. When he initially woke up after being hit and came to, his abilities were not the same, he was using his hands but nothing else like he had before. The interview revealed Resident #49 started trying to go in the wrong direction and had to be redirected by staff, they took him to his new room, and it took Scheduler #1, NA #2 and Nurse #3 to all assist him into the bed. Scheduler #1 stated she left the building at 3:00 PM. She stated they were so concerned with Resident #49's condition they had placed a fall mat under his bed because they felt like he may have a fall from the bed due to his state of immobility. Scheduler #1 stated she did not voice her concerns to anyone because she thought Nurse #3 and Nurse #4 were communicating the Resident's changes to the Medical Provider. On 11/19/24 at 12:52 PM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she was responsible for Resident #49 on 09/14/24 during first shift (7:00 AM to 3:00 PM). She stated she did not witness the incident but was notified of what had happened by Nurse #3. NA #2 recalled she was told by Nurse #3 to take the resident outside to smoke and to move Resident #49's belongings out of his room into a new room on another unit. NA #2 indicated she moved Resident #49's belongings and assisted him from the smoking area to his new room around 10:00 AM and assisted him into the bed which was different from that morning. Earlier in morning, he was able to transfer himself. The interview revealed when she went to the smoking area to get Resident #49, he did not have a cigarette and was just sitting outside. NA #2 stated she immediately noticed a difference in the way Resident #49 was responding and moving around 9:30 AM when she took him to the smoking area. He was unable to self-propel his wheelchair. NA #2 stated Resident #49 could not assist her at all for bed mobility and had to remain in bed for the rest of her shift. NA #2 stated she did not recall Resident #49 eating lunch on 09/14/24. Resident #49 had gone from being able to transfer himself that morning to being unable to roll from left to right in the bed following the incident occurring around 10:00 AM and providing incontinent care while the resident was in the bed. NA #2 also noted Resident #49 seemed slow to respond when spoken to immediately following the altercation. NA #2 stated she had discussed Resident #49's change of condition with both Nurse #3 and Nurse #4 as soon as she assisted Resident #49 into his bed that morning. NA #2 stated she was not given instructions to obtain vital signs on Resident #49 during first shift and gave report to NA #1 at 3:00 PM. On 11/19/24 at 2:00 PM an interview was conducted with NA #1. During the interview she stated she came on shift at 3:00 PM and received a report from NA #2. She and Unit Manager #1 assisted Resident #49 to his wheelchair because his legs were dangling off of the bed. NA #1 noted Resident #49 to be disoriented, leaning back in his wheelchair, sliding out of his wheelchair and overall, not looking like he typically did sitting up, self-propelling himself in a regular wheelchair in the hallway. Resident #49 was incontinent of urine and staff were changing his brief while he was in bed. NA #1 remembered having assisted him back up in his wheelchair during that evening and he eventually had a fall around 6:30 to 7:00 PM after sliding completely out of his wheelchair into the floor in the hallway. The interview revealed Resident #49 was sent to the hospital for an evaluation. NA #1 stated she did not recall obtaining vital signs for Resident #49 nor was she asked about his condition. The interview revealed she had notified Nurse #4 during her shift around 4:00 PM that Resident #49 seemed different from his baseline state. A late entry incident report dated 09/14/24 at 11:02 PM written by Nurse #4 revealed Resident #49 had experienced a fall and was found in the hallway sitting on his bottom around 6:30 PM. Resident #49 stated he had slid off his wheelchair. No injuries were observed however the resident was sent to the hospital due to recent change in cognition. On 11/19/24 at 2:49 PM an interview was conducted with Nurse #4. She stated she was in the building on 09/14/24 during the first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM). The interview revealed Resident #49 was moved to her hall following an altercation with his roommate where he was hit in the back of the head. She stated she assumed Resident #49's care for second shift at 3:00 PM. She stated she did not recall the exact time the resident was moved to her unit. The interview revealed Resident #49 was noted to be in bed, which was not typical for him. Nurse #4 stated she was not very familiar with the resident however she did know he was typically up during the day. She stated the nurse aides were telling her he was experiencing a significant change of condition from his normal baseline. She stated she did not contact the on-call provider. The interview revealed Resident #49 was gotten up to his wheelchair for the supper meal and he kept sliding out of the wheelchair. Nurse #4 had to obtain other staff members to assist her to pull him up in his chair. She stated around 6:30 PM Resident #49 was noted to fall out of his wheelchair into the floor in the hallway. The interview revealed he was immediately sent to the hospital for an evaluation based on the nurse aides telling her of the resident's drastic change of condition. Nurse #4 stated she had known Resident #49 was independent in his wheelchair, however when he left to go to the hospital, he was dependent upon staff for all transfers. On 11/21/24 at 9:06 AM an interview was conducted with Unit Manager (UM) #1. During the interview UM #1 stated on 09/14/24 around 9:00 AM she was paged on the overhead call system to come to Resident #49's room around 9:00 AM. Upon arrival Nurse #3 told her Resident #49 had been hit on the back of his head by his roommate. UM #1 stated she looked at the Resident and he was able to respond to her. UM #1 had NA #2 remove Resident #49 from the room and contacted the Director of Nursing (DON) who stated she (UM #1) needed to notify the resident's family and the provider on call. (UM #1) stated the provider on call (NP#3) asked her how the resident was doing, and UM #1 stated it was her first time laying eyes on him, and he seemed okay so she told the provider he seemed fine with no injuries. NP #3 instructed the facility to notify her of any change of condition. UM #1 stated NA #2 immediately moved Resident #49 to another room around 10:00 AM. Unit Manager #1 stated as she was rounding later in the day around 2:30 PM and saw Resident #49's call light on, she stated he was trying to transfer himself from the wheelchair to the toilet which the NA said he was normally able to do. UM #1 stated she had to get two other staff members to assist due to his observed weakness. She stated Resident #49 was so weak she asked the Resident to hold off on all transfers for the rest of the day because he was a full assist. She contacted NP #2 who told her she would be in the building to round shortly. UM #1 stated the DON told her to activate Emergency Medical Services (EMS) because she did not feel comfortable with his condition. EMS arrived at the same time as NP #2 came onsite around 3:00 PM. NP #2 completed an assessment of Resident #49 and stated to her (UM #1) to turn EMS away because the resident had no reason to go out for an evaluation. She stated shortly after she had them turn EMS away, Resident #49 slid out of his wheelchair onto his bottom. Unit Manager #1 called NP#2 and stated Resident #49 was going to be sent to the hospital for an evaluation. UM #1 stated the staff had moved Resident #49 to his wheelchair because his legs kept dangling off of the bed and she was afraid he was going to fall. On 11/22/24 at 9:38 AM an interview was conducted with Nurse Practitioner #3. During the interview she stated she was the on-call Nurse Practitioner assigned to the facility on [DATE]. NP #3 stated she did recall being notified of an altercation with Resident #49 around 9:00 AM but did not recall specific details of the incident or who notified her. NP #3 stated if she was notified a resident was struck in the head she would recommend sending the resident to the hospital for an evaluation. She stated she was not contacted by the facility for Resident #49 anymore that day because they had an in-house NP (NP #2) who was rounding on the residents. The interview revealed she did not have any notes from the day as to what orders she gave the facility. An SBAR (Situation, Background, Assessment and Recommendation) Summary dated 09/14/24 at 3:35 PM written by Unit Manager #1 revealed Resident #49 had experienced a change of condition after a physical altercation with another resident. The chief complaint was listed as Resident #49 had become increasingly weak on the left side after a physical altercation at the hands of another resident. The on- call provider was notified of the resident's condition and instructions were placed to activate Emergency Medical Services (EMS) for an evaluation at the Emergency Department. A SBAR (Situation, Background, Assessment and Recommendation) Summary dated 09/14/24 at 3:35 PM written by Unit Manager #1 revealed Resident #49 had experienced a change of condition after a physical altercation with another resident. The chief complaint was listed as Resident #49 had become increasingly weak on the left side after a physical altercation at the hands of another resident. The on- call provider was notified of the residents' condition and instructions were placed to activate Emergency Medical Services (EMS) for an evaluation at the Emergency Department. On 11/22/24 at 9:14 AM an interview was conducted with Nurse Practitioner #2. She stated she was an in-house provider that rounds in the facility on the weekends. She stated she remembered evaluating Resident #49 while he was sitting in a chair and did not know what had happened that morning with an altercation. NP#2 stated she only recalled sending the resident out to the hospital following a fall and did not recall telling anyone to stop EMS from coming at 3:00 PM. She stated when the resident became unstable and fell , she sent him out. EMS records dated 09/14/24 revealed they were dispatched to the facility with a chief complaint of increased weakness and a fall after an assault earlier in the morning. The resident had a history of TBI and wanted to be evaluated. Resident #49 stated he was hit in the head by his roommate earlier in the morning around 9:00 AM. He stated the roommate used his fist to hit him in the head and denied loss of consciousness. Staff, however, said the resident lost consciousness. The resident was cleared initially by his facility physician (NP #2) to stay at the facility and not be transported to the hospital. Around 6:30 PM Resident #49 was sitting in his wheelchair, when he tried to reposition himself. He had increased weakness that caused him to slide down the chair onto the floor. Resident #49 was noted to be on the floor until a medic arrived. Hospital records dated 09/14/24 revealed Resident #49 was evaluated on this date after sliding out of his wheelchair around 6:30 PM. Per the Medic the resident was also punched in the head by his roommate earlier in the morning around 9:30 AM but cleared by the facility. A computed tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility with strict precautions to return with any new or worsening symptoms. Hospital records dated 09/17/24 revealed Resident #49 presented to the hospital for evaluation of acute chronic left-sided weakness. The resident was reported to be punched in the head by a roommate three days prior. He was originally evaluated in the Emergency Department on 09/14/24 and cleared for discharge. He presented back to the hospital complaining of lightheadedness and felt that his left side was weaker than his baseline from prior brain injury. He was also complaining of blurred vision and headaches. Resident #49 was admitted for neuroimaging. The exam showed a decreased edema signal within the brainstem (indicating potential damage or abnormality within the brainstem region) since the prior exam. Neurology was consulted with orders to follow up outpatient. The note revealed the Neurologist felt the findings could represent post concussive changes in the setting of extensive chronic progressive leukoencephalopathy (a rare, progressive brain infection that destroys cells that produce myelin, an insulating material for nerve cells). Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. On 11/19/24 at 3:12 PM an interview was conducted with Resident #49. During the interview he stated he had gotten hit in the back of the head by his former roommate a couple of months prior. The interview revealed he was sitting in the doorway when his roommate came at him from behind. Resident #49 revealed he did not recall any details about what had occurred after he was hit and did not remember going to the hospital after the incident. He stated since the incident he felt his condition had changed and he could no longer transfer himself from his bed to the wheelchair or self-propel in his wheelchair. The interview revealed he no longer was able to use his regular wheelchair which was still located outside of his room door because he was no longer able to sit up in it. Resident #49 stated he was now confined to a specialized chair and was dependent upon staff for all activities of daily living (ADL). He stated he was unable to assist himself to the toilet to use the restroom so he was now having to wear a brief and reliant of staff to change him. He stated two nurse aides used the mechanical lift to change him. On 11/20/24 at 11:02 AM an interview was conducted with the Medical Director (MD). The MD stated the nurse was responsible for contacting the on-call provider and notifying them of the change of condition. On 11/20/24 at 2:51 PM an interview was conducted with the Director of Nursing. She stated she was notified by Unit Manager #1 early in the morning around 9:00 on 09/14/24 that Resident #49 was hit in the head by his roommate and had no injuries. The interview revealed she was unaware Resident #49 had experienced any change of condition on 09/14/24. The interview revealed if a resident had a change of condition the on-call provider should be notified immediately. On 11/20/24 at 3:17 PM an interview was conducted with the Administrator. During the interview he stated he was notified about the altercation on a weekend day. The interview revealed the Administrator was unaware of any change of condition on the date of 09/14/24. The Administrator was notified of the immediate jeopardy on 11/20/24 at 4:17 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. - On 09/14/24 at 9:05 AM Nurse #3 heard a loud hit or thud coming from across the unit. She then noted Resident #49's wheelchair rolling out from his room with him in the wheelchair and witnessed his roommate swing his arm with a fist and hit Resident #49 on the back of the head. Based on staff interview Resident #49 had a significant change of condition recognized by sliding out of his wheelchair, decrease in level of assistance with transfers, a decrease in bed mobility and confusion. - On 9/14/2024 Unit Manger #1 notified the on-call Nurse Practitioner (NP #3) at approximately 10:00 AM to report the altercation with the roommate and change in level of care needs, as more assistance was needed with transfers as it took several people to get him into the bed. The Nurse Practitioner (NP #2) arrived at the facility at approximately 3:20 PM and examined the resident related to mental status changes after an altercation with his roommate. The Nurse Practitioner arrived at the same time as EMS who had been called by the nurses and upon examination by the NP, the NP determined that the resident did not need to go out to the hospital, so EMS was turned away. - The on-call Nurse Practitioner (NP #2) was notified at approximately 6:15 PM after Resident #49 was noted to be lying on the floor after sliding out of his wheelchair with Altered Mental Status (AMS). Resident was sent to the hospital for further evaluation due to a concern for a concussion from the hit to the back of Resident's head on 09/14/24. Hospital records indicate no acute trauma or concussion diagnosed related to the event. Resident #49 returned to the emergency roiagnom on [DATE] and was admitted for further neurological workup to include a Magnetic Resonance Imaging (MRI). MRI showed redemonstration of severe infratentorial and infratentorial white matter signal abnormality mildly worsened since prior MRI of 2020. It showed decreased edema signal within the brainstem, moderate ventriculomegaly, secondary to white matter volume loss. There was no acute infarction. No significant vascular disease. MRI of the Cervical Spine showed severe C4-5 left foraminal stenosis. - On 11/21/24 and 11/22/24, a nursing assessment was completed by the Licensed Nurses to verify all residents were currently stable and were not experiencing a change in condition requiring notification to the physician for further orders. The nursing assessment results are noted in the residents' electronic health record. The DON reviewed the results of the Licensed Nurse assessments and the 24-hour report to ensure there were no residents experiencing a change in condition requiring notification to the physician for further orders. Additionally, the DON reviewed the 24-hour report to ensure no other incidents requiring notification to the provider for which the Medical Provider had not been notified. No adverse outcomes were identified in this audit. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. - Nurse #3 was re-educated on notification of medical provider per the policy and procedure for a resident with a change in condition on 11/22/24 based on the urgency of the situation to include but not be limited to falls, resident to resident altercations, injuries, unstable vital signs, head trauma and indwelling catheter with recurrent symptomatic urinary tract infections, or recurrent pneumonia, changes in skin color or condition. - All licensed nurses, agency/contract staff, and all newly hired licensed nursing employees along with Certified Nurse Aides will be educated on proper notifications to the Medical Provider or to the On Call Provider after hours and on weekends when a resident has a change in condition or incident, immediately after the incident or immediately at the time when a change in condition occurs. The On Call After Hours provider numbers are posted at each nurses' station. Education will be completed by the DON/Nurse Manager on 11/22/2024. Nursing staff not educated by 11/22/2024 will be educated prior to the start of their next scheduled shift. This education will be completed in person or by telephone. Education for newly hired staff will be completed by the Director of Nursing/Nurse Manager during the orientation period. Staff who were not educated on 11/22/2024 either in person or by telephone will be educated prior to the start of their next scheduled shift. The DON is responsible for tracking staff who still require education. The DON/Licensed Nurse Manager will provide education to staff not educated by 11-22-24 prior to the start of the next scheduled shift. DON and Licensed Nurse Manager were notified of this responsibility on 11-22-24. The Administrator will be responsible for the completion of the immediate jeopardy removal plan. The immediate jeopardy removal date is 11/23/2024. On 10/27/22, the credible allegation of immediate jeopardy removal date of 11/23/24 was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on proper notifications to the Medical Provider or to the On Call Provider after hours and on weekends when a resident has a change in condition or incident, immediately after the incident or immediately at the time. The facility's in-service log and training material was reviewed. The IJ removal date of 11/23/24 was validated.

Based on observations, record review, and resident, facility staff, Nurse Practitioner (NP), Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to protect a resident's right to be from physical abuse (Resident #49). On 09/14/24 at approximately 9:00 AM Nurse #3 heard a loud hit or thud coming from across the unit and then observed Resident #49 rolling out of his room in his wheelchair and witnessed Resident #79 swinging his arm with a fist and hit Resident #49 on the back of the head. Resident #49 was noted to slump over in his wheelchair and have a loss of consciousness for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of a traumatic brain injury and immediately after being hit in the head by Resident #79 he was noted to have a change of condition as evidenced by a change in level of assistance needed for transfer and bed mobility changed, confusion and inability to self-propel in his wheelchair. Later in the day Resident #49 slid out of wheelchair to the floor and was assessed with worsening generalized weakness and concern for a concussion. Emergency Medical Services (EMS) was dispatched on 9/14/24 at 6:31 PM and Resident #49 was taken to the hospital for evaluation. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. Resident #49 returned to the hospital on 9/17/24 for evaluation of acute chronic left-sided weakness, lightheadedness, blurred vision and headaches. Resident #49 was admitted for neuroimaging (brain scanning). The Neurologist felt the findings could represent post concussive changes and Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. At the time of the survey, Resident #49 reported he felt his condition had changed since the incident and noted he was now confined to a specialized chair and was dependent upon staff for all activities of daily living and required the use of mechanical lift for transfers. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #49). Immediate Jeopardy began on 09/14/24 when Resident #49 who had a history of a traumatic brain injury was hit with a closed fist in the back of the head by Resident #79. The immediate jeopardy was removed on 11/23/24 when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #49 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI). A review of Resident #49's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #49 was coded as independent for eating and putting on/ taking off footwear. He required set up or clean up assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #49 required supervision assistance for chair to bed transfers, toileting transfers, tub/shower transfers and lying to sitting on the side of the bed. The resident was noted to be independent for rolling left and right while in bed. Resident #49 was continent of bowel and bladder during the assessment period and was documented to have no behaviors. Resident #79 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of TBI. A review of Resident #79's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #79 was coded as independent for all activities of daily living (ADL) including eating, toileting, oral hygiene, shower/bathe self, upper body dressing, lower body dressing and all transfers. He was coded as using a cane to ambulate during the assessment period. Resident #79 was documented to have no behaviors. A review of the facility's investigation report initiated on 09/14/24 at 9:05 AM by the Administrator revealed Resident #49 was hit on the back of his neck/head by his roommate. After the nurse assessed Resident #49, he was noted with no injuries and the residents were immediately separated by moving Resident #49 to another room. Staff were briefed on the incident and monitored the residents every 15 minutes to avoid further incidents. Resident #49's roommate had stated he hit the resident because he was trying to exit the room and Resident #49 was blocking the doorway with his wheelchair. A nursing note written by Nurse #3 dated 09/14/24 at 10:11 AM revealed she heard hitting noises and turned around to observe Resident #49 get hit in the head by his roommate. The note revealed the residents were separated and assessed for injuries. Resident #49's vital signs were the following: blood pressure 138/66, pulse 72, temperature 97.9, respirations 20, oxygen saturation level 96% on room air. The resident was noted with no signs of acute distress at the time of the incident and no complaints of pain. Redness was noted to the back of the resident's neck. The residents Responsible Party, Director of Nursing and on call Nurse Practitioner were notified. New orders were obtained for a psychological evaluation of Resident #79 and every 15-minute monitoring for a duration of 24 hours. On 11/19/24 at 11:38 AM an interview was conducted with Nurse #3. Nurse #3 stated on 09/14/24 around 9:00 AM she heard a loud hit or thud coming from across the unit. She then saw Resident #49 rolling out from his room in his wheelchair and witnessed (Resident #79) who was cognitively intact, swinging his arm with a fist and hit Resident #49 at the back of the head making a second thud sound as his fist hit the back of Resident #49's head. Resident #49 immediately slumped over in his wheelchair and regained consciousness within a couple of seconds after she got to him to assess his condition. She stated she saw redness at the back of Resident #49's head and neck area. When Resident #49 came to he asked to go outside to smoke so Nurse Aide (NA) #2 took him to the smoking area. Nurse #3 indicated she had obtained initial vital signs on the resident which were within normal range, assessed him and the Unit Manager notified the Nurse Practitioner of what had occurred. Nurse #3 explained when Resident #49 was moved from her hall around 10:00 AM, she no longer was his nurse and did not see him again that day. On 11/21/24 at 12:32 PM an interview was conducted with Scheduler #1. She stated she was working as the Manager on Duty on 09/14/24. Scheduler #1 stated her office door was open and she overheard a nurse screaming for help. When she went out into the hall, she saw Nurse #3 and went to her. Scheduler #1 stated Resident #49 sitting in his wheelchair slumped over and was unconscious for approximately a minute. Nurse #3 explained to her that he had just been hit in the back of the head by Resident #79. When he initially woke up after being hit and came to, his abilities were not the same, he was using his hands but nothing else like he had before. She stated he was no longer able to self-propel himself in the hallway as he had done that morning or self-transfer to bed. After separating the residents, she stated she notified the Unit Manager #1 via the facility paging system and Nurse #3 called the Director of Nursing. Scheduler #1 stated Resident #49 was taken to the smoking area by NA#2 because he stated he wanted to go smoke. She stated Resident #49 immediately seemed spaced out by responding slowly when spoken to and not thinking clearly. The interview revealed Resident #49 started trying to go in the wrong direction and had to be redirected by staff. When they took him to his new room, it took Scheduler #1, NA #2 and Nurse #3 to all assist him into the bed. Scheduler #1 told Nurse #3 she would need to complete neurological assessments. She stated they were so concerned with Resident #49's condition they had placed a fall mat under his bed because they felt like he may have a fall from the bed due to his state of immobility. On 11/21/24 at 9:06 AM an interview was conducted with Unit Manager (UM) #1. During the interview she stated on 09/14/24 around 9:00 AM she was paged on the overhead call system to come to Resident #49's room. Upon arrival Nurse #3 told her Resident #49 had been hit on the back of his head by Resident #79. She stated she looked at the resident and he was able to respond to her. She had them remove Resident #49 from the room and contacted the Director of Nursing (DON) who stated she needed to notify the resident's family and the provider on call. She stated the provider on call (NP #3) asked her how the resident was doing, and she stated it was her first time laying eyes on him, and he seemed okay. UM #1 recalled they immediately moved Resident #49 to a room in another hall around 10:00 AM. Unit Manager #1 stated she was rounding later in the day and saw Resident #49's call light on, she stated he was trying to transfer himself from the wheelchair to the toilet which the NA said he was normally able to do. She stated she had to get two other staff members to assist due to his weakness. On 11/19/24 at 12:52 PM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she was responsible for Resident #49 on 09/14/24 during first shift (7:00 AM to 3:00 PM). She stated she did not witness the incident but was notified of what had happened by Nurse #3. NA #2 recalled she was told by Nurse #3 to move Resident #49's belongings out of his room into a new room on another unit. NA #2 indicated she moved Resident #49's belongings and assisted him from the smoking area to his new room around 10:00 AM and assisted him into the bed which was different from that morning. Earlier in morning, he was able to transfer himself. NA #2 stated she had discussed Resident #49's change of condition with both Nurse #3 and Nurse #4 as soon as she assisted Resident #39 into his bed in the new room that morning. NA #2 stated she immediately noticed a difference in the way Resident #49 was responding and moving. NA #2 stated Resident #49 could not assist her at all for bed mobility and had to remain in bed for the rest of her shift. NA #2 explained she decided to continue to provide care to the resident despite him being on another unit due to staffing concerns. NA #2 indicated Resident #49 had gone from being able to transfer himself that morning to being unable to roll from left to right in the bed following the incident. For the remainder of the shift Resident #49 was provided with incontinent care in bed, which was a change of condition. NA #2 also noted Resident #49 seemed slow to respond when she spoke to him. On 11/19/24 at 2:00 PM an interview was conducted with NA #1. During the interview she stated she came on shift at 3:00 PM and received report from NA #2. She and the Unit Manager #1 assisted Resident #49 to his wheelchair because his legs were dangling off of the bed around 4:00 PM. NA #1 noted Resident #49 to be disoriented, leaning back in his wheelchair, sliding out of his wheelchair and overall, not looking like he typically did, sitting up, self-propelling himself in a regular wheelchair in the hallway. NA #1 indicated she was changing Resident #49's brief while he was in bed, which was a change as he could usually transfer himself to the bathroom. NA #1 remembered having to assist him back up in his wheelchair during that evening and he eventually slid completely out of his wheelchair into the floor in the hallway around 6:30 to 7:00 PM. On 11/19/24 at 2:49 PM an interview was conducted with Nurse #4. She stated she was in the building on 09/14/24 during the first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM). The interview revealed Resident #49 was moved to her hall following an altercation with Resident #79 during which Resident #79 hit Resident #49 on the back of his head. She stated she assumed Resident #49's care for second shift at 3:00 PM. The interview revealed Resident #49 was noted to be in bed, which was not usual because he was typically up and out in the facility in the hallway during the day. Nurse #4 stated the NA #1 and NA #2 were telling her he was experiencing a significant change of condition from his normal baseline by being in bed, a decrease in mobility, decreased alertness and incontinence throughout the day. Nurse #4 explained Resident #49 was gotten up to his wheelchair for the supper meal and he kept sliding out of the wheelchair and Nurse #4 had to obtain other staff members to assist her to pull him up in his chair. Nurse #4 indicated around 6:30 PM Resident #49 was noted to fall out of his wheelchair onto the floor in the hallway. A late entry incident report dated 09/14/24 at 11:02 PM written by Nurse #4 revealed Resident #49 had experienced a fall and was found in the hallway sitting on his bottom around 6:30 PM. Resident #49 stated he had slid off his wheelchair. No injuries were observed however the resident was sent to the hospital due to recent change in cognition. On 11/19/24 at 3:12 PM an interview was conducted with Resident #49. During the interview Resident #49 stated he had gotten hit in the back of the head by Resident #79 a couple of months prior. The interview revealed he was sitting in the doorway when Resident #79 came at him from behind. Resident #49 revealed he did not recall any details about what had occurred after he was hit and did not remember going to the hospital after the incident. He felt his condition had changed since the incident and noted he could no longer transfer himself from his bed to the wheelchair or self-propel in his wheelchair. Resident #49 revealed he was no longer able to use his regular wheelchair, which was still located outside of his room, because he was no longer able to sit up in it. Resident #49 stated he was now confined to a specialized chair and was dependent upon staff for all activities of daily living and required the use of mechanical life for transfers. He stated he was unable to transfer himself to the toilet to use the restroom and was having to wear a brief, urinate on himself, and reliant on staff to change him. A Nurse Practitioner note written by NP #2 on 09/15/24 as late entry for 09/14/24 revealed she was asked to see Resident #49 for altered mental status after an altercation in which the resident ended up on the floor knocked out cold, he did not hit his head and regained consciousness right away but now seen with altered mental status. At the time of the assessment, although he was able to follow simple commands, he was noted to have worsening generalized weakness drop in extremity sitting in the chair. She was noted to be concerned for a concussion and escalated the resident to the emergency room for an evaluation and management. On 11/22/24 at 9:14 AM an interview was conducted with Nurse Practitioner #2. She stated she was an in-house provider that rounded in the facility on the weekends. She stated she remembered evaluating Resident #49 while he was sitting in a chair, but NP #3 was originally notified that morning about an altercation. NP #2 stated staff did tell her the resident had been hit in the head by his roommate and had experienced altered mental status. However, she did not witness the incident and therefore it was only hearsay. She stated when the resident became unstable and fell , she sent him out. Review of the Emergency Medical Services (EMS) dispatch log for the facility on 09/14/24 revealed they were notified to respond for Resident #49 at 6:31 PM due to a fall in which the resident slipped from his chair to the floor. EMS arrived at the facility and transported Resident #49 to the hospital. EMS records dated 09/14/24 revealed they were dispatched to the facility with a chief complaint of increased weakness and a fall after an assault earlier in the morning. The resident had a history of TBI and wanted to be evaluated. Resident #49 stated he was hit in the head by Resident #79 earlier in the morning around 9:00 AM. He stated Resident #79 used his fist to hit him in the head and denied loss of consciousness. Staff, however, did say the resident lost consciousness. The resident was cleared initially by his facility physician to stay at the facility and not be transported to the hospital. Around 6:30 PM Resident #49 was sitting in his wheelchair, when he tried to reposition himself, he had increased weakness that caused him to slide down the chair onto the floor. The resident was noted to be on the floor when the medic arrived. Resident #49 was mechanically lifted into the medic's stretcher. EMS documented the resident's vital signs at 6:52 PM to include the following: blood pressure 120/76, pulse 70 beats per minute (bpm), respirations 16, oxygen saturation level 94% (normal >92%). Resident #46 was noted to be oriented to person, place and time. The resident stated to EMS he felt safe at the facility, however, would like a new roommate. The note read, Patient is requesting we transport him to the hospital for further evaluation. Hospital records dated 09/14/24 revealed Resident #49 was evaluated on this date after sliding out of his wheelchair around 6:30 PM. Per the Medic the resident was also punched in the head by his roommate earlier in the morning around 9:30 AM but cleared by the facility. The residents' diagnoses included fall, closed head injury and generalized weakness. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. A nursing progress note dated 09/15/24 at 6:55 AM revealed Resident #49 had returned to the facility from the hospital by EMS transport. Resident #49 was noted to be in no acute distress or discomfort. A Nurse Practitioner note dated 09/16/24 written by NP #1 revealed she was asked to evaluate Resident #49 on this date by the Director of Nursing (DON) due to the resident being sent to the Emergency Department (ED) after he was forcefully hit in the head by his roommate and had experienced a couple of falls since the incident. Resident #49 was noted to have been evaluated for a close head injury while in the hospital. At the time of her assessment the resident was noted to be in a stable condition with no complaints of pain or weakness. During the evaluation he was noted to be in bed resting with no acute distress. On 11/19/24 at 3:36 PM an interview was conducted with Nurse Practitioner #1. During the interview she stated Resident #49 was sent to the hospital on 09/14/24 following a fall in the facility. She stated she was not in the facility or on call the weekend the incident occurred but learned of the altercation the following Monday after returning to the facility. NP #1 stated Resident #49 had experienced two falls after returning back to the facility from the hospital and she was asked to evaluate him on 09/16/24 following the second fall. Resident #49 was in no distress during her evaluation. The interview revealed Resident #49 started experiencing headache, weakness and lightheadedness on 09/17/24 while she was in the building and was sent back to the hospital. He was discharged back to the facility on [DATE]. NP #1 stated she had written a progress note on 10/21/24 discussing the hospital course and they had conducted a neurological work up while the resident was in the hospital. She stated the hospital notes did discuss the resident could have had post concussive findings meaning it was possible he had experienced a concussion from the incident, but they were unable to determine if it was that or a past misdiagnosis. NP #1 stated Resident #49 is now in a specialized wheelchair that leaned back unlike the chair he was in prior to the incident which was a regular wheelchair. She stated once he came back from the hospital, he was slow to respond with occasional headaches and was not as active as he was prior to the incident. She stated it was possible the effects he has experienced could be from the altercation, but the resident had other conditions that could have contributed to the changes he had experienced. Hospital records dated 09/17/24 revealed Resident #49 presented to the hospital for evaluation of acute chronic left-sided weakness. The resident was reported to have been punched in the head by a roommate 3 days prior. He was originally evaluated in the Emergency Department on 09/14/24 and cleared for discharge. He presented back to the hospital complaining of lightheadedness and felt that his left side was weaker than his baseline from prior brain injury. He was also complaining of blurred vision and headaches. Resident #49 was admitted for neuroimaging. The exam showed a decreased edema signal within the brainstem (indicating potential damage or abnormality within the brainstem region) since the prior exam. Neurology was consulted with orders to follow up outpatient. The note revealed the Neurologist felt the findings could represent post concussive changes in the setting of extensive chronic progressive leukoencephalopathy (a rare, progress brain infection that destroys cells that produce myelin, an insulating material for nerve cells). The resident's hospital course included a full stroke workup resulting in no findings of a stroke, Physical Therapy and Occupational Therapy evaluation, lab workup and inpatient neurology evaluation. Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. On 11/20/24 at 11:02 PM an interview was conducted with the Medical Director (MD). The MD stated she had only been in the facility since September 2024 and was not familiar with Resident #49's prior state. She stated she knew of the incident occurring, but the on-call Nurse Practitioner was notified since the incident occurred on a weekend. The MD indicated the resident was sent to the hospital following a fall in the hallway and his CT at the hospital was negative, so he was sent back to the facility. The interview revealed Resident #49 continued to have symptoms of a concussion, so he was sent to the hospital for a reevaluation on 09/17/24. The MD explained it could take a couple of days for symptoms of a concussion to appear. She stated at the hospital there were changes from his previous MRI with a decreased signal to the brainstem which she felt couldn't have happened from a hit to the resident's head. Neurology was consulted while Resident #49 was hospitalized and mentioned post concussive findings in their note, however they were also ruling out a possible misdiagnosis in the past. The interview further revealed concussion symptoms would have included lightheadedness, light sensitivity and blurred vision, all which Resident #49 was noted to have during his 09/17/24 hospitalization . On 11/27/24 at 2:05 PM an interview was conducted with the Neurologist Physician Assistant. She stated she had evaluated Resident #49 during his follow up appointment on 10/18/24. She stated the resident was being seen due to an abnormal brain MRI, white matter disease, left side numbness, incoordination and weakness. The PA stated she had only seen the resident during a one-time snapshot, and it is very hard to say the findings came directly from the altercation. She stated she had ordered follow up blood work, a lumbar puncture and was going to be reevaluating Resident #49 at the first of the year to see if there was a possible relationship between the altercation and the changes the resident has experienced. On 11/20/24 at 2:51 PM an interview was conducted with the Director of Nursing (DON). The DON stated she was notified early in the morning around 9:00 on 09/14/24 that Resident #49 was hit in the head by Resident #79. She stated Resident #49 was sitting in his wheelchair in the doorway of the room and Resident #79 wanted to get out of the room. On 11/20/24 at 3:17 PM an interview was conducted with the Administrator. During the interview he stated he was notified about the altercation on a weekend day. Staff had told him Resident #79 had popped Resident #49 on the back of the neck. The Administrator stated based on his understanding of what had happened that day staff did not make it seem like Resident #49 was hit hard by Resident #79. He was unaware Resident #79 used a fist to swing and hit Resident #49 in the back of the head. The Administrator was notified of the Immediate Jeopardy on 11/20/24 at 4:17 PM. The facility provided the following Credible Allegation of immediate jeopardy removal. Plan for Removal of Immediate Jeopardy for F600 Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: The facility failed to protect Resident #49's rights to be from physical abuse. On 09/14/2024 at 9:05 AM Nurse #1 heard a loud hit or thud coming from across the unit. She then noted Resident #49's wheelchair rolling out from his room with the resident in the wheelchair and witnessed his roommate who was cognitively intact swing his arm with a fist and hit Resident #49 in the back of the head. Resident #49 was noted to slump over in his wheelchair for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of traumatic brain injury. On 9/14/2024 at approximately 3:20pm, Resident #49 was seen by the Nurse Practitioner at the facility at the same time that Emergency Medical Services arrived. After assessing the resident, the Nurse Practitioner did not feel the resident needed to go to the hospital for further treatment despite the knowledge that Resident #49 had an altercation with the roommate and was struck in head with a significant decline from baseline as reported by several staff during the observation period. On 09/14/2024, at approximately 9:05 AM Resident #49 was separated from his roommate by the nurse and was assessed by the nurse. Resident #49 was then moved to another room away from the roommate to ensure their safety. The 15-minute safety checks are done by nursing staff to ensure residents are visualized and placed and not in harm's way. The 15-minute safety checks were initiated for both Resident #49 and his roommate. On 09/14/2024, Resident #49 and the roommate had a skin check performed by a licensed nurse status post the event to check for apparent injuries without findings. On 9/14/2024 at 7:00 PM the nurse called the Nurse Practitioner gave the order to send Resident #49 out to the hospital related to the resident sliding out of his chair and in conjunction with significant changes in condition related to Resident #49's altered mental status, and increased need for assistance with transfer mobility and bed mobility. On 11/22/2024 the Nurse Manager and the Social Services Director completed interviews with residents with a Brief Interview for Mental Status (BIMS) of 13 and above were interviewed to ensure no abuse or neglect. On 11/21/2024, current residents with a Brief Interview for Mental Status (BIMS) of 12 and below had skin checks performed by a licensed nurse and documented on a skin inspection sheet, to ensure no suspicious injuries or indication of abuse or neglect. On 11/22/2024, the Administrator and the Director of Clinical Services reviewed the incident log for the past 30 days for any other potential abuse allegations needing to be self-reported to the state of North Carolina without any further instances noted. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 11/22/2024, current residents with targeted physical behaviors of becoming aggressive to others were identified by the Interdisciplinary Team to include the Administrator, Director of Nursing, Medical Director, Nurse Practitioner, Social Services Director, Activities Director, Therapy Director. On 11/22/2024, current residents with targeted physical behaviors care plans and behavior monitoring tools were reviewed and updated as needed by the Interdisciplinary Team to ensure interventions are in place for safety. On 11/21/2024, the Regional Director of Clinical Services reviewed the policy with and completed re-education of the facility's policy and procedures for abuse and neglect with the Administrator and the Director of Nursing to ensure understanding with a verbal return demonstration as to the types of abuse and neglect to include but not be limited to delay of care and treatment or sending a resident to a higher level of care when they have a significant change in condition. Additionally, education included what to do if you witness abuse and neglect, when to report abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator, who is the facility administrator. On 11/22/2024, the Director of Nursing and Nurse Managers completed re-education with all current staff, including Dietary, Housekeeping, Laundry, administration, Maintenance, Social Services, Therapy, Activities, Department Managers, Nursing, including Licensed Nurses, Medication Aides and Certified Nursing Assistants, including agency staff on the facility's policy and procedure for abuse and neglect to ensure understanding with a verbal return demonstration as to the types of abuse and neglect to include but not be limited to delay of care and treatment or sending a resident to a higher level of care when they have a significant change in condition. Additionally, education included what to do if you witness abuse and neglect, when to report abuse and neglect, to whom to report abuse and neglect and the designated facility abuse coordinator, who is the facility administrator. This education for the nursing staff will be the responsibility of the DON/Licensed Nurse Manager for current staff. Staff who were not educated on 11/22/2024 either in person or by telephone will be educated prior to the start of their next scheduled shift. The DON is responsible for tracking staff who still require education. The DON/Licensed Nurse Manager will provide education to staff not educated by 11-22-24 prior to the start of the next scheduled shift. DON and Licensed Nurse Manager were notified of this responsibility on 11-22-24. Education will be done by the DON/RN Nurse Manager during the orientation period for any newly hired staff ongoing, including agency staff for abuse and neglect. An Ad-Hoc Quality Assurance Performance Improvement Committee was held on 11/21/2024, which included the Regional Clinical Director, Medical Director, the Director of Nursing, Administrator, Maintenance Director, Unit Managers, Social Service Director, Activities Director, Rehab Program Manager and a Certified Nursing Assistant to formulate and approve a plan of correction for the deficient practice. The Administrator will be responsible for the completion of the corrective action plan. Alleged date of IJ removal: 11/23/2024 On 10/27/22, the credible allegation of Immediate Jeopardy removal date of 11/23/24 was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including Dietary, Housekeeping, Laundry, administration, Maintenance, Social Services, Therapy, Activities, Department Managers, Nursing, including Licensed Nurses, Medication Aides and Certified Nursing Assistants, and agency staff on the facility's policy and procedure for abuse and neglect revealed they had received in-service training regarding spotting, identifying, and reporting abuse. Records were reviewed of residents identified with targeted physical behaviors. A sample of residents were interviewed to ensure they had been asked about abuse and neglect by the facility. Skin assessments were reviewed for residents with a BIMS score of less than 12. < [TRUNCATED]

Based on observations, record review, and resident, facility staff, Nurse Practitioner (NP), Medical Director (MD), and Physician Assistant (PA) interviews, the facility staff failed to recognize the seriousness of a significant change in condition, complete comprehensive and ongoing assessments, and identify the need for urgent medical attention. On 09/14/24 at 9:05 AM Nurse #3 heard a loud hit or thud coming from across the unit and then observed Resident #49 rolling out of his room in his wheelchair and witnessed Resident #79 swinging his arm with a fist and hit Resident #49 on the back of the head. Resident #49 was noted to slump over in his wheelchair and have a loss of consciousness for a few seconds before opening his eyes and requesting to go outside and smoke. Resident #49 had a history of a traumatic brain injury and immediately after being hit in the head by Resident #79 he was noted to have a change of condition as evidenced by a change in level of assistance needed for transfer and bed mobility changed, confusion and inability to self-propel in his wheelchair. There was a lack of effective communication between staff after Resident #49 was transferred to a different hall around 10:00 AM and no care or assessments were provided by a nurse until 3:00 PM. There were no documented comprehensive assessments or neurological checks located in the medical record after the initial nursing note after the incident. Later in the day Resident #49 slid out of wheelchair to the floor and was assessed with worsening generalized weakness and concern for a concussion. Emergency Medical Services (EMS) was dispatched on 9/14/24 at 6:31 PM and Resident #49 was taken to the hospital for evaluation. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. Resident #49 returned to the hospital on 9/17/24 for evaluation of acute chronic left-sided weakness, lightheadedness, blurred vision and headaches. Resident #49 was admitted for neuroimaging (brain scanning). The Neurologist felt the findings could represent post concussive changes and Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. At the time of the survey, Resident #49 reported he felt his condition had changed since the incident and noted he was now confined to a specialized chair and was dependent upon staff for all activities of daily living and required the use of mechanical lift for transfers. In addtion, the facility failed to assess a resident for injury before moving them when Driver #1 was transporting Resident #55 in the facility van and he fell backwards in his wheelchair and hit his head on the van floor resulting in severe head pain. Driver #1 lifted Resident #55 back into an upright position and drove him back to the facility without being assessed by a medical professional. Driver #1 had not been trained on how to respond or what to do in emergency situation or accident. Resident #55 was assessed by Nurse #1 and noted to have a swollen area with abrasions to the back of his head. Resident #55 was transferred to the hospital for further evaluation and was diagnosed with a closed head injury, scalp abrasion and strained neck muscles. This deficient practice occurred for 2 of 3 sampled residents reviewed for quality of care (Resident #49 and Resident #55). Immediate Jeopardy began on 09/14/24 when Resident #49 who had a history of a traumatic brain injury was hit in the head and facility staff failed to identify the seriousness of the change in condition and complete comprehensive assessments to determine if a higher level of care was needed. Immediate jeopardy began for Resident #55 on 11/15/24 when he was lifted back into an upright position by Driver #1 before he was assessed for injury by a medical professional. The immediate jeopardy was removed for Resident #55 on 11/22/24 and for Resident #49 on 11/23/24 when the facility implemented an acceptable credible allegation. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: 1. Resident #49 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of traumatic brain injury (TBI). A review of Resident #49's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #49 was coded as independent for eating and putting on/ taking off footwear. He required set up or clean up assistance for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and personal hygiene. Resident #49 required supervision assistance for chair to bed transfers, toileting transfers, tub/shower transfers and lying to sitting on the side of the bed. The resident was noted to be independent for rolling left and right while in bed. Resident #49 was continent of bowel and bladder during the assessment period and was documented to have no behaviors. Resident #79 was a [AGE] year-old admitted to the facility on [DATE] with a diagnosis of TBI. A review of Resident #79's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #79 was coded as independent for all activities of daily living (ADL) including eating, toileting, oral hygiene, shower/bathe self, upper body dressing, lower body dressing and all transfers. He was coded as using a cane to ambulate during the assessment period. Resident #79 was documented to have no behaviors. A review of the facility's investigation report initiated on 09/14/24 at 9:05 AM by the Administrator revealed Resident #49 was hit on the back of his neck/head by his roommate. After the nurse assessed Resident #49, he was noted with no injuries and the residents were immediately separated by moving Resident #49 to another room. Staff were briefed on the incident and monitored the residents every 15 minutes to avoid further incidents. Resident #49's roommate had stated he hit the resident because he was trying to exit the room and Resident #49 was blocking the doorway with his wheelchair. An Occupation Therapy (OT) discharge summary dated 09/06/24 revealed Resident #49 received therapy services initiated on 07/18/24 through 09/06/24. Skilled interventions provided included instructing and training Resident #49 in proper body mechanics, positioning/ pressure relieving techniques, safe transfer techniques and use of adaptive equipment in order to improve independence and engagement of ADL and self-care task. At the time of therapy discharge Resident #49 was set up assistance for eating, partial/moderate assistance for toileting hygiene, supervision for toileting transfers and set up assistance for bathing. The resident's self-care function score on a scale of 0-12 (12 being the highest function of independence) was a 10. A nursing note written by Nurse #3 dated 09/14/24 at 10:11 AM revealed she heard hitting noises and turned around to observe Resident #49 get hit in the head by his roommate. The note revealed the residents were separated and assessed for injuries. Resident #49's vital signs were the following: blood pressure 138/66, pulse 72, temperature 97.9, respirations 20, oxygen saturation level 96% on room air. The resident was noted with no signs of acute distress at the time of the incident and no complaints of pain. Redness was noted to the back of the resident's neck. The residents Responsible Party, Director of Nursing and on call Nurse Practitioner were notified. New orders were obtained for a psychological evaluation of Resident #79 and every 15-minute monitoring for a duration of 24 hours. A review of Resident #49's medical record revealed the only documented vital signs were included on Nurse #3's progress note on 9/14/24 at 10:11 AM. Further review of the medical record revealed no neurological or resident assessments were documented. On 11/19/24 at 11:38 AM an interview was conducted with Nurse #3. Nurse #3 stated on 09/14/24 around 9:00 AM she heard a loud hit or thud coming from across the unit. She then saw Resident #49 rolling out from his room in his wheelchair and witnessed (Resident #79) who was cognitively intact, swinging his arm with a fist and hit Resident #49 at the back of the head making a second thud sound as his fist hit the back of Resident #49's head. Resident #49 immediately slumped over in his wheelchair and regained consciousness within a couple of seconds after she got to him to assess his condition. She stated she saw redness at the back of Resident #49's head and neck area. When Resident #49 came to he asked to go outside to smoke so Nurse Aide (NA) #2 took him to the smoking area. Nurse #3 indicated she had obtained initial vital signs on the resident which were within normal range, assessed him and the Unit Manager notified the Nurse Practitioner of what had occurred. Nurse #3 explained when Resident #49 was moved from her hall around 10:00 AM, she no longer was his nurse and did not see him again that day. The interview revealed she had initiated an action rounding log which documented where the resident was in the facility every 15 minutes. Upon review of the action rounding sheet Nurse #3 confirmed her initials were on the sheet documenting on the resident from 9:00 AM to 3:00 PM, however she did not recall putting her initials on the paper nor had she checked on the resident every 15 minutes during the shift. Nurse #3 stated Nurse #4 took over Resident #49's care when he moved to his new room around 10:00 AM. Nurse #3 gave Nurse #4 a short description of what had occurred between the two residents and went back to her unit. The interview revealed the facility would typically complete neurological assessments after a head injury, however since Nurse #4 assumed responsibility for the resident it would have been up to her to complete the assessments and monitoring. Nurse #3 stated she did not initiate neuro checks for the resident. On 11/21/24 at 12:32 PM an interview was conducted with Scheduler #1. She stated she was working as the Manager on Duty on 09/14/24. Scheduler #1 stated her office door was open and she overheard a nurse screaming for help. When she went out into the hall, she saw Nurse #3 and went to her. Scheduler #1 stated Resident #49 sitting in his wheelchair slumped over and was unconscious for approximately a minute. Nurse #3 explained to her that he had just been hit in the back of the head by Resident #79. When he initially woke up after being hit and came to, his abilities were not the same, he was using his hands but nothing else like he had before. She stated he was no longer able to self-propel himself in the hallway as he had done that morning or self-transfer to bed. After separating the residents, she stated she notified the Unit Manager #1 via the facility paging system and Nurse #3 called the Director of Nursing. Scheduler #1 stated Resident #49 was taken to the smoking area by NA#2 because he stated he wanted to go smoke. She stated Resident #49 immediately seemed spaced out by responding slowly when spoken to and not thinking clearly. The interview revealed Resident #49 started trying to go in the wrong direction and had to be redirected by staff. When they took him to his new room, it took Scheduler #1, NA #2 and Nurse #3 to all assist him into the bed. Scheduler #1 told Nurse #3 she would need to complete neurological assessments. She stated they were so concerned with Resident #49's condition they had placed a fall mat under his bed because they felt like he may have a fall from the bed due to his state of immobility. Scheduler #1 stated she did not voice her concerns to anyone because she thought Nurse #3 and Nurse #4 were communicating the residents' changes to the Medical Provider. The interview revealed Resident #49 had experienced a couple of falls following the incident and was sent back to the hospital on 09/17/24 for a reevaluation due to complaints of a headache. On 11/21/24 at 9:06 AM an interview was conducted with Unit Manager (UM) #1. During the interview she stated on 09/14/24 around 9:00 AM she was paged on the overhead call system to come to Resident #49s room. Upon arrival Nurse #3 told her Resident #49 had been hit on the back of his head by Resident #79. She stated she looked at the resident and he was able to respond to her. She had them remove Resident #49 from the room and contacted the Director of Nursing (DON) who stated she needed to notify the resident's family and the provider on call. She stated the provider on call (NP #3) asked her how the resident was doing, and she stated it was her first time laying eyes on him, and he seemed okay. NP #3 instructed the facility to notify them of any change of condition. UM #1 recalled they immediately moved Resident #49 to a room in another hall around 10:00 AM. She stated it was her understanding after talking with Nurse #3 that Nurse #4 was going to assume care of the resident when he moved to the new room. Unit Manager #1 stated she was rounding later in the day and saw Resident #49's call light on, she stated he was trying to transfer himself from the wheelchair to the toilet which the NA said he was normally able to do. She stated she had to get two other staff members to assist due to his weakness. She stated Resident #49 was so weak she asked the Resident to hold off on all transfers for the rest of the day because he was now a full assist for transfers. She contacted Nurse Practitioner (NP) #2 who told her she would be in the building to round shortly. UM #1 explained she spoke with the DON after she called NP #2 to let her know NP #2 was going to evaluate the resident. UM #1 revealed the DON told her to activate Emergency Medical Services (EMS) because she did not feel comfortable with his condition. EMS arrived at the same time as NP #2 came onsite around 3:00 PM. NP #2 completed an assessment of Resident #49 and stated to her (UM #1) to turn EMS away, that the resident had no reason to go out for an evaluation. UM #1 indicated she disagreed with the decision, however, went along with it and sent a message to the DON letting her know EMS was turned away. UM #1 indicated shortly after she had them turn EMS away the resident was in his wheelchair he slid out of his wheelchair onto his bottom. She stated the staff had moved Resident #49 to his wheelchair because his legs kept dangling off of the bed and she was afraid he was going to fall. Unit Manager #1 indicated after Resident #49 slid out of his wheelchair she called NP #2 and notified her Resident #49 was going to be sent to the hospital for an evaluation. On 11/22/24 at 9:38 AM an interview was conducted with NP #3. During the interview she stated she was the on-call provider assigned for the facility on 09/14/24 (Saturday). NP #3 stated she did recall being notified of an altercation with Resident #49 around 10:00 AM but did not recall the details of the phone conversation of what she was told by the nurse. She stated typically if she was notified a resident was struck in the head she would recommend sending the resident to the hospital for an evaluation. She stated she was not contacted by the facility for Resident #49 anymore that day because they had an in-house NP (NP #2) that was rounding on the residents. The interview revealed she did not have any notes from the day as to what orders she gave the facility. On 11/19/24 at 12:52 PM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she was responsible for Resident #49 on 09/14/24 during first shift (7:00 AM to 3:00 PM). She stated she did not witness the incident but was notified of what had happened by Nurse #3. NA #2 recalled she was told by Nurse #3 to take Resident #49 outside to smoke and to move Resident #49's belongings out of his room into a new room on another unit. NA #2 indicated she moved Resident #49's belongings and assisted him from the smoking area to his new room around 10:00 AM and assisted him into the bed which was different from that morning. Earlier in morning, he was able to transfer himself. The interview revealed when she went to the smoking area to get Resident #49, he did not have a cigarette and was just sitting outside. NA #2 stated she had discussed Resident #49's change of condition with both Nurse #3 and Nurse #4 as soon as she assisted Resident #39 into his bed in the new room that morning. NA #2 stated she immediately noticed a difference in the way Resident #49 was responding and moving. NA #2 stated Resident #49 could not assist her at all for bed mobility and had to remain in bed for the rest of her shift. NA #2 explained she decided to continue to provide care to the resident despite him being on another unit due to staffing concerns. NA #2 indicated Resident #49 had gone from being able to transfer himself that morning to being unable to roll from left to right in the bed following the incident. For the remainder of the shift Resident #49 was provided with incontinent care in bed, which was a change of condition. NA #2 also noted Resident #49 seemed slow to respond when she spoke to him. NA #2 stated she was not given instructions to obtain vital signs on Resident #49 during first shift and gave report to NA #1 at 3:00 PM. On 11/19/24 at 2:00 PM an interview was conducted with NA #1. During the interview she stated she came on shift at 3:00 PM and received report from NA #2. NA #1 recalled she and the Unit Manager #1 assisted Resident #49 to his wheelchair because his legs were dangling off of the bed around 4:00 PM. NA #1 noted Resident #49 to be disoriented, leaning back in his wheelchair, sliding out of his wheelchair and overall, not looking like he typically did, sitting up, self-propelling himself in a regular wheelchair in the hallway. NA #1 indicated Resident #49 usually transferred himself to the bathroom but that shift he was incontinent, and she was changing Resident #49's brief while he was in bed which was a change. NA #1 remembered having to assist him back up in his wheelchair during that evening and he eventually slid completely out of his wheelchair into the floor in the hallway around 6:30 to 7:00 PM. The interview revealed Resident #49 was sent to the hospital for an evaluation. NA #1 stated she did not recall obtaining vital signs for Resident #49 nor was she asked about his condition. The interview revealed she had notified Nurse #4 during her shift around 4:00 PM that Resident #49 seemed different from his baseline state. On 11/19/24 at 2:49 PM an interview was conducted with Nurse #4. She stated she was in the building on 09/14/24 during the first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM). The interview revealed Resident #49 was moved to her hall following an altercation with Resident #79 during which Resident #79 hit Resident #49 on the back of his head. She stated she assumed Resident #49's care for second shift at 3:00 PM. The interview revealed Resident #49 was noted to be in bed, which was not usual because he was typically up and out in the facility in the hallway during the day. Nurse #4 indicated she did not report the change of condition to the Medical Provider. Nurse #4 stated the NA #1 and NA #2 were telling her he was experiencing a significant change of condition from his normal baseline by being in bed, a decrease in mobility, decreased alertness and incontinence throughout the day. Nurse #4 explained Resident #49 was gotten up to his wheelchair for the supper meal and he kept sliding out of the wheelchair and Nurse #4 had to obtain other staff members to assist her to pull him up in his chair. Nurse #4 indicated around 6:30 PM Resident #49 was noted to fall out of his wheelchair onto the floor in the hallway. Resident #49 was immediately sent to the hospital for an evaluation based on the nurse aides telling her of the resident's drastic change of condition and the fall. Nurse #4 stated prior to the incident Resident #49 was independent in his wheelchair, however when he left to go to the hospital, he was dependent upon staff for transfers using a mechanical lift. Nurse #4 recalled she had completed an action rounding sheet starting at 3:00 PM on Resident #49 which meant every 15 minutes the staff were documenting where the resident was in the facility. She stated they did not have to complete vital signs on a schedule or neurological assessments on the resident because she thought Nurse #3 had completed them. Nurse #4 thought the first shift nurse had taken care of the neurological assessments and the resident until 3:00 PM. She explained that Nurse #3 had initialed the action rounding sheet during the first shift. Nurse #4 stated she did not receive report from Nurse #3, it was just known around the facility what had happened to Resident #49 and why he had to change rooms. The interview revealed Nurse #4 did not know she was supposed to assume the residents care when he initially moved to the new room around 10:00 AM because typically if a resident moved the nurse initially responsible would continue to care for them throughout the shift until the next shift arrived. Nurse #4 further stated after the resident came back from the hospital, she had taken care of him during second shift on 09/15/24 when he experienced a fall out of bed. The resident stated he was trying to fix himself in the bed and had just slipped down onto the fall mat located to the side of his bed. She stated he did not report hitting his head and was placed back in bed. The on-call physician was notified on 09/15/24 at 11:40 PM of the fall and stated to monitor the resident. Nurse #4 confirmed she did not assess or provide any care to Resident #49 until 3:00 PM. A SBAR (Situation, Background, Assessment and Recommendation) Summary dated 09/14/24 at 3:35 PM written by Unit Manager #1 revealed Resident #49 had experienced a change of condition after a physical altercation with another resident. The chief complaint was listed as Resident #49 had become increasingly weak on the left side after a physical altercation at the hands of another resident. The on- call provider was notified of the residents' condition and instructions were placed to activate Emergency Medical Services (EMS) for an evaluation at the Emergency Department. Review of the Emergency Medical Services dispatch log for the facility on 09/14/24 revealed they were initially notified to respond for Resident #49 at 3:33 PM due to a physical decline after a physical altercation. EMS was en route to the facility at 3:47 PM and cancelled at 4:04 PM. A Nurse Practitioner note written by NP #2 on 09/15/24 as late entry for 09/14/24 revealed she was asked to see Resident #49 for altered mental status after an altercation in which the resident ended up on the floor knocked out cold, he did not hit his head and regained consciousness right away but now seen with altered mental status. At the time of the assessment, although he was able to follow simple commands, he was noted to have worsening generalized weakness drop in extremity sitting in the chair. She was noted to be concerned for a concussion and escalated the resident to the emergency room for an evaluation and management. On 11/22/24 at 9:14 AM an interview was conducted with Nurse Practitioner #2. She stated she was an in-house provider that rounded in the facility on the weekends. She stated she remembered evaluating Resident #49 while he was sitting in a chair, but NP #3 was originally notified that morning about an altercation. NP #2 stated staff did tell her the resident had been hit in the head by his roommate and had experienced altered mental status. However, she did not witness the incident and therefore it was only hearsay. NP #2 stated she only recalled sending the resident out to the hospital following a fall around 6:30 PM and did not recall telling anyone to stop EMS from coming at 3:00 PM. A late entry incident report dated 09/14/24 at 11:02 PM written by Nurse #4 revealed Resident #49 had experienced a fall and was found in the hallway sitting on his bottom around 6:30 PM. Resident #49 stated he had slid off his wheelchair. No injuries were observed however the resident was sent to the hospital due to recent change in cognition. Review of the Emergency Medical Services (EMS) dispatch log for the facility on 09/14/24 revealed they were notified to respond for Resident #49 at 6:31 PM due to a fall in which the resident slipped from his chair to the floor. EMS arrived at the facility and transported Resident #49 to the hospital. EMS records dated 09/14/24 revealed they were dispatched to the facility with a chief complaint of increased weakness and a fall after an assault earlier in the morning. The resident had a history of TBI and wanted to be evaluated. Resident #49 stated he was hit in the head by Resident #79 earlier in the morning around 9:00 AM. He stated Resident #79 used his fist to hit him in the head and denied loss of consciousness. Staff, however, did say the resident lost consciousness. The resident was cleared initially by his facility physician to stay at the facility and not be transported to the hospital. Around 6:30 PM Resident #49 was sitting in his wheelchair, when he tried to reposition himself, he had increased weakness that caused him to slide down the chair onto the floor. The resident was noted to be on the floor when the medic arrived. Resident #49 was mechanically lifted into the medic's stretcher. EMS documented the resident's vital signs at 6:52 PM to include the following: blood pressure 120/76, pulse 70 beats per minute (bpm), respirations 16, oxygen saturation level 94% (normal >92%). Resident #46 was noted to be oriented to person, place and time. The resident stated to EMS he felt safe at the facility, however, would like a new roommate. The note read, Patient is requesting we transport him to the hospital for further evaluation. Hospital records dated 09/14/24 revealed Resident #49 was evaluated on this date after sliding out of his wheelchair around 6:30 PM. Per the Medic the resident was also punched in the head by his roommate earlier in the morning around 9:30 AM but cleared by the facility. The residents' diagnoses included fall, closed head injury and generalized weakness. A Computed Tomography (CT) scan was completed which resulted in no acute findings. Resident #49 was discharged back to the nursing facility on 9/15/24 with strict precautions to return with any new or worsening symptoms. A nursing progress note dated 09/15/24 at 6:55 AM revealed Resident #49 had returned to the facility from the hospital by EMS transport. Resident #49 was noted to be in no acute distress or discomfort. An incident report dated 09/15/24 at 11:38 PM written by Nurse #4 revealed Resident #49 had an unwitnessed fall and was found on the floor of his room. The resident stated to the nurse that he was trying to fix himself in the bed. No injuries were observed at the time of the incident and the resident denied hitting his head. A Nurse Practitioner on call was notified of the fall and stated to monitor the resident for any changes. An incident report dated 09/16/24 at 6:15 AM written by Nurse #5 revealed Resident #49 had experienced an unwitnessed fall and was observed laying on his back on the floor of his room. His legs and feet were noted to be tangled in his sheets while he was on the floor. Resident #49 denied hitting his head, he stated he had slid with the covers landing on his bottom and his back. No open or bruised areas were noted to the residents' body. NP #1 was notified of the fall on 09/16/24 at 7:54AM. An interview was attempted with Nurse #5 on 11/20/24 at 10:35 AM with no return phone call received to the surveyor. A Nurse Practitioner note dated 09/16/24 written by NP #1 revealed she was asked to evaluate Resident #49 on this date by the Director of Nursing (DON) due to the resident being sent to the Emergency Department (ED) after he was forcefully hit in the head by his roommate and had experienced a couple of falls since the incident. Resident #49 was noted to have been evaluated for a close head injury while in the hospital. At the time of her assessment the resident was noted to be in a stable condition with no complaints of pain or weakness. During the evaluation he was noted to be in bed resting with no acute distress. On 11/19/24 at 3:36 PM an interview was conducted with Nurse Practitioner #1. During the interview she stated Resident #49 was sent to the hospital on 09/14/24 following a fall in the facility. She stated she was not in the facility or on call the weekend the incident occurred but learned of the altercation the following Monday after returning to the facility. NP #1 stated Resident #49 had experienced two falls after returning back to the facility from the hospital and she was asked to evaluate him on 09/16/24 following the second fall. Resident #49 was in no distress during her evaluation. The interview revealed Resident #49 started experiencing headache, weakness and lightheadedness on 09/17/24 while she was in the building and was sent back to the hospital. He was discharged back to the facility on [DATE]. NP #1 stated she had written a progress note on 10/21/24 discussing the hospital course and they had conducted a neurological work up while the resident was in the hospital. She stated the hospital notes did discuss the resident could have had post concussive findings meaning it was possible he had experienced a concussion from the incident, but they were unable to determine if it was that or a past misdiagnosis. NP #1 stated Resident #49 is now in a specialized wheelchair that leaned back unlike the chair he was in prior to the incident which was a regular wheelchair. She stated once he came back from the hospital, he was slow to respond with occasional headaches and was not as active as he was prior to the incident. She stated it was possible the effects he has experienced could be from the altercation, but the resident had other conditions that could have contributed to the changes he had experienced. Hospital records dated 09/17/24 revealed Resident #49 presented to the hospital for evaluation of acute chronic left-sided weakness. The resident was reported to have been punched in the head by a roommate 3 days prior. He was originally evaluated in the Emergency Department on 09/14/24 and cleared for discharge. He presented back to the hospital complaining of lightheadedness and felt that his left side was weaker than his baseline from prior brain injury. He was also complaining of blurred vision and headaches. Resident #49 was admitted for neuroimaging. The exam showed a decreased edema signal within the brainstem (indicating potential damage or abnormality within the brainstem region) since the prior exam. Neurology was consulted with orders to follow up outpatient. The note revealed the Neurologist felt the findings could represent post concussive changes in the setting of extensive chronic progressive leukoencephalopathy (a rare, progress brain infection that destroys cells that produce myelin, an insulating material for nerve cells). The resident's hospital course included a full stroke workup resulting in no findings of a stroke, Physical Therapy and Occupational Therapy evaluation, lab workup and inpatient neurology evaluation. Resident #49 was discharged back to the facility on [DATE] with orders to follow up with neurology outpatient. A Nurse Practitioner note written by NP #1 revealed Resident #49 was evaluated on 09/23/24 after a reevaluation post hospitalization regarding altered mental status. The resident was noted to have been recently sent to the Emergency Department (ED) after being hit in the head by another resident. He was evaluated in the ED and cleared for discharge. However, after his return to the facility he had a decline with altered mental status and was sent back for further evaluation. Resident #49 was admitted for further neurological imaging. The plan included concussion/leukoencephalopathy/closed head injury. Neurology felt the resident had post concussive findings in

Based on observations, record review, resident, Medical Director and staff interviews, the facility failed to provide safe van transportation when Driver #1 failed to secure Resident #55's wheelchair in the facility van per the manufacturer's instructions. On 11/15/24, during transport from the dialysis center, Driver #1 did not secure Resident #55's wheelchair in the facility van per the manufacturer's instructions, and when he drove out of the parking lot and turned right onto the main road, Resident #55 fell backwards in his wheelchair and hit his head on the van floor. Resident #55 was assessed by Nurse #1 when he returned to the facility, was noted to have an abrasion and swelling to the back of his head and was complaining of severe head pain. He was transported to the Emergency Department (ED) for further evaluation and diagnosed with a closed head injury, scalp abrasion, and strained neck muscles. There was a high likelihood of a serious adverse outcome or injury when Resident #55's wheelchair was not secured in the transportation van per the manufacturer's instructions. Resident #55 was not receiving an anticoagulant (blood thinner). This deficient practice occurred for 1 of 9 residents reviewed for accidents (Resident #55). Immediate jeopardy began on 11/15/24 when Resident #55's wheelchair was not secured in the facility's transport van per the manufacturer's instructions, and he fell backwards in his wheelchair and hit his head on the van floor. Immediate jeopardy was removed on 11/19/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: A review of the manufacturer's instruction manual for the transport van 4-point wheelchair securement system provided by the facility read in part: Attach the tie-down (fabric strap connecting a hook and a floor anchor) anchor into the floor anchorages and lock them into place. Attach the 4 tie-down hooks to a solid part of the wheelchair frame below the seat ensuring the tie downs are fixed at approximately 45 degrees. Ensure all tie-downs are locked and properly tensioned (tightened). A review of Driver #1's training records revealed a competency evaluation dated 11/12/24 completed by the Former Administrator that Driver #1 was reviewed for securing a wheelchair into the facility's transport van per the manufacturer's instructions and all competencies were checked as met. Resident #55 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, right below the knee amputation, abnormalities of gait/mobility and muscle weakness. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was cognitively intact, had lower extremity impairment on one side, utilized a manual wheelchair for mobility, required supervision to moderate assistance with transfers and was receiving dialysis treatment. The MDS further revealed Resident #55 was not coded for receiving an anticoagulant. A review of the Care Plan dated 11/13/24 indicated Resident #55 required minimal to extensive assistance with activities of daily living, was a right lower extremity amputee with a prosthesis, utilized a wheelchair to assist with mobility and received dialysis treatment 3 days a week. A review of the facility incident report dated 11/15/24 written by Nurse #1 indicated Resident #55 was being transported in the facility van from dialysis and when the van started moving forward, he fell backwards in his wheelchair and hit his head. Resident #55 returned to the facility and Nurse #1 completed a full body assessment. Resident #55 had an area to the back of his head with a small amount of bleeding, redness, and swelling. Resident #55 was alert and oriented and his vital signs were stable. Nurse #1 cleaned the area to his head and applied a border gauze dressing (absorbent gauze pad with a sticky border to hold it in place). Resident #55 was complaining of head pain and requested to go to the hospital. The on-call physician was notified, an order was received and Resident #55 was transported to the emergency department (ED) via emergency medical services for further evaluation. A review of the ED records dated 11/15/24 revealed Resident #55 reported he fell backwards in his wheelchair in a transport van hitting his head on the van floor. He was noted to have a wound to the back of his head with the bleeding controlled prior to his arrival at the ED. A computed tomography (CT) scan of the head and spine, and x-rays of the pelvis and chest were obtained. The CT scan results were negative for intracranial hemorrhage (brain bleed) and fractures, the x-rays were also negative for any fractures and the scalp abrasion did not require any treatment. Resident #55 was stable and discharged back to the facility with diagnoses including closed head injury, scalp abrasion, and strain of the neck muscle. A review of Driver #1's statement dated 11/15/24 indicated he picked up Resident #55 from the dialysis center loaded him in the transportation van and secured his wheelchair. Driver #1 was pulling out of the parking lot onto the main road when he heard Resident #55 yelling whoa, whoa, and he looked back to find Resident #55 had fallen backwards in his wheelchair. Driver #1 immediately pulled over into a parking lot and stopped the van, waved down a person to help and they lifted Resident #55 back into an upright position. Driver #1 noted Resident #55 had a small amount of blood on the back of his head which he cleaned with an alcohol wipe. Driver #1 secured Resident #55's wheelchair, started driving back to the facility and called Unit Manager #1 to inform her of the incident. Upon returning to the facility, Driver #1 took Resident #55 to the nurse's station and informed the nurse of the incident. In an interview with Driver #1 on 11/19/24 at 2:02 PM he indicated the Former Administrator trained him on how to secure a wheelchair in the facility van on 11/12/24. Driver #1 indicated he watched the Former Administrator secure a wheelchair in the van using the manufacturer instructions. Driver #1 stated the Former Administrator then observed him secure an empty wheelchair in the van, and then the Former Administrator sat in a wheelchair, he secured it in the van and drove the van out of the parking lot and on the main road for a few minutes to ensure the wheelchair was properly secured. Driver #1 indicated the Former Administrator filled out a vehicle safety and operation competency evaluation and he was checked off for meeting the competencies for proper placement and securement of the wheelchair. Driver #1 stated he started transporting residents in the facility van on 11/13/24 and transported 3 residents to appointments on that day without incident. Driver #1 indicated on 11/15/24 around 11:00 AM he picked up Resident #55 from the dialysis center, secured his wheelchair in the transport van, and started to drive out of the parking lot. He stated when he accelerated the van and turned onto the main road, Resident #55 began yelling whoa, whoa, and when he looked back Resident #55 had fallen backwards in his wheelchair. Driver #1 indicated he drove about 200-300 feet, pulled over into a parking lot, and stopped the van. He stated he went to the back of the van and Resident #55 was tipped over in his wheelchair and lying on his right side. Driver #1 stated he observed that the front left anchor on the tiedown strap had come loose from the floor anchorage. He indicated he asked Resident #55 if he was ok and he said he was. Driver #1 stated he waved down a person in the parking lot to help and they lifted Resident #55 back into an upright position. Driver #1 revealed he secured Resident #55's wheelchair making sure all of the tie-down anchors were locked into the floor anchorages and then drove back to the facility. He stated that while he was driving back to the facility he called and reported the incident to Unit Manager #1. Driver #1 indicated when he arrived at the facility, he took Resident #55 to the nurse's station and reported the incident to Nurse #1. An interview with Resident #55 on 11/19/24 at 12:36 PM indicated the facility transports him to dialysis on Mondays, Wednesdays and Fridays. He stated Driver #1 transported him in the facility van for the first time on 11/13/24. Resident #55 revealed when the van was moving his wheelchair was moving around a little and he did not feel properly secured but did not report this to Driver #1. Resident #55 indicated Driver #1 transported him to dialysis on 11/15/24 and on the way back to the facility when he drove out of the parking lot and turned onto the main road, he fell backwards in his wheelchair and hit his head on the van floor. Resident #55 stated Driver #1 stopped the van and asked if he was injured, and he told him his head hurt. He stated that Driver #1 waved down a person to come and help and they lifted him back into an upright position. Resident #55 revealed that Driver #1 secured his wheelchair and drove him back to the facility. He stated a nurse assessed him when he returned to the facility but he did not recall her name. Resident #55 indicated he told the nurse he was having severe head pain and that he wanted to go to the hospital. He revealed the nurse called 911 and he was transferred to the ED for further evaluation. An interview was conducted with Unit Manager #1 on 11/20/24 at 10:06 AM. Unit Manager #1 revealed on 11/15/24 she received a phone call from Driver #1 informing her that Resident #55 fell backwards in his wheelchair while being transported in the facility's van. She stated she asked Driver #1 how it happened, and he told her the tie-downs were not secured properly and came loose. Unit Manager #1 indicated Driver #1 informed her he lifted Resident #55 back into an upright position and there was a little blood on the back of his head he wiped off. She revealed Driver #1 reported no other injuries, so she told him to bring Resident #55 back to the facility. An interview with Nurse #1 on 11/20/24 at 10:21 AM indicated she was assigned to Resident #55 on 11/15/24. She stated Driver #1 returned to the facility with Resident #55 after his dialysis appointment and informed her the resident fell backwards in his wheelchair in the van and hit his head on the floor. Nurse #1 revealed she completed a head-to-toe assessment and noted Resident #55 had a large swollen area to the right back side of his head with abrasions and a small amount of bleeding. She indicated Resident #55 did not have hair, so she was able to clean the area and applied a gauze border dressing. She stated that Resident #55 was complaining of severe head pain and requested to go to the hospital. She revealed she administered Resident #55 pain medication ordered as needed, called the on-call physician and obtained an order to transfer Resident #55 to the ED for further evaluation. An interview conducted with the Former Administrator on 11/19/24 at 3:08 PM indicated on 11/07/24 the facility's transport driver resigned, and the facility's part time receptionist (Driver #1) was hired as the transport driver. He stated on 11/12/24 he trained Driver #1 by showing him how to secure a wheelchair in the transport van using the manufacturer instructions for the 4-point wheelchair securement system and then watched Driver #1 secure an empty wheelchair in the van. The Former Administrator revealed he then sat in a wheelchair while Driver #1 secured it in the van and drove the van out of the parking lot and on the main road. He indicated Driver #1 secured the wheelchair properly and no concerns were identified. The Former Administrator stated he filled out the facility's vehicle safety and operation competency evaluation and Driver #1 met all the competencies on the form including proper placement and securement of the wheelchair per the manufacturer instructions. An interview conducted with the Medical Director on 11/20/24 at 11:01 AM indicated she was aware of the van incident that occurred with Resident #55. She stated she was informed Resident #55's wheelchair was not secured properly in the transport van and when the van started moving, he fell backwards in his wheelchair hitting his head on the van floor. The Medical Director revealed that residents should be secured properly in the transport van and a resident that fell should be evaluated by a medical professional prior to being moved to prevent further injury. An interview with the Administrator on 11/19/24 at 3:30 PM revealed he started working at the facility on 11/12/24. He stated he was aware of the incident that occurred on 11/15/24 involving Resident #55. He indicated Driver #1 had not secured Resident #55's wheelchair and when the van started moving Resident #55 fell backwards in his wheelchair and hit his head on the van floor. The Administrator indicated Driver #1 lifted Resident #55 back into an upright position, secured his wheelchair and drove him back to the facility. The Administrator stated Resident #55's wheelchair should have been properly secured in the transport van. The Administrator was notified of immediate jeopardy on 11/20/24 at 2:04 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the non-compliance: On 11/15/2024 at approximately 11:20 AM Resident #55 had a fall in the facility van during return from dialysis when the wheelchair tipped backwards and Resident #55 struck his head on the van floor resulting in an injury to the back of his head and pain. The facility Transportation Driver failed to provide safe van transportation for Resident #55 by not securing his wheelchair in the transportation van per the manufacturer's instructions. On 11/15/2024 at approximately 11:30 AM Resident #55 returned to the facility. The nurse immediately assessed Resident #55 including Head-to-Toe assessment, Range of Motion all extremities, pupils equal, round and reactive to light and accommodation, and completed a pain assessment. Resident #55 was alert and oriented x 4 per baseline. Resident #55 sustained a hematoma to the back of his head with a small abrasion noted to the area. First aid was provided by the nurse to the area on resident's head, and medications administered per schedule and pain medication administered. The resident reported to the nurse that when the van moved, he fell backwards and hit his head. The nurse called 911 and sent Resident #55 out via emergency medical services at approximately 12:01 PM. The Director of Nursing and the Nurse Practitioner were notified along with Resident #55's Responsible Party. On 11/15/2024 the facility Transportation Driver was suspended pending investigation, and the facility van was removed from service until the Regional Maintenance Director inspection was complete. On 11/15/2024 an Investigation immediately initiated by the Director of Nursing, which included an interview and the visualization of return demonstration by the facility Transportation Driver. The facility Transportation Driver stated that Resident #55 was strapped into the van with all 4 wheelchair restraints and the seat belt. The wheelchair locks were also locked on both wheels. The facility Transportation Driver stated he pulled out of the parking lot, turning right, when he heard Resident #55 say whoa, he looked in the mirror and saw Resident #55 fall backward to the side. The conclusion is that a strap was not fully engaged in the track which allowed the wheelchair to come loose and fall backwards, whereby the resident hit his head. On 11/15/2024, at approximately 5:49 PM, Resident #55 returned from the Emergency Department status post Computed Tomography Scan which was negative. No orders were received from the emergency room . Upon return to the facility, neurological checks were initiated. Head to toe skin assessment and pain assessment completed. Resident #55 complained of headache, and Hydrocodone/Acetaminophen 5/325mg was administered by the nurse as ordered. Resident #55 was alert and oriented per baseline. Upon Resident #55's return to the facility the Nurse Practitioner was notified, and an order was given to apply ice to the back of Resident #55's head and an additional order to cleanse the area and apply a dry dressing to his head daily and as needed. On 11/15/2024 the Director of Nursing scheduled all resident transport with contracted transportation company until further notice. On 11/15/2024 Head-to-toe skin assessments were completed for all residents on the transportation schedule for the facility van from 11/13/2024-11/15/2024 as a precaution since van driver had only started driving the van on 11/13/2024. No concerns were identified. Alert and oriented residents that had been scheduled for transportation on the facility van from 11/13/2024-11/15/2024 were asked if they felt safe and secure on the van during transport. No concerns were identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 11/15/2024, at approximately 12:20 PM immediate education was provided via phone by the Regional Director of Clinical Services to the Administrator and Director of Nursing. This education included Vehicle Driver Safety Program, proper use of wheelchair securement devices per manufacturer's instructions, vehicle lift competency evaluation, placing the van out of service immediately, and not allowing the facility transportation driver to drive until investigation completed. On 11/15/2024, at approximately 3:00 PM, Immediate education provided by the Director of Nursing to the facility Transportation Driver. This written and verbal education included Vehicle Driver Safety Program, proper use of wheelchair securement devices as per manufacturer's instructions, vehicle lift competency evaluation, placing the van out of service immediately, not allowing the facility transportation driver to drive until investigation completed. On 11/15/2024, the Contracted Transportation company provided the facility with their policy and procedures for securing and strapping a wheelchair and competencies for the 2 current drivers. The education and competencies are completed upon hire and annually. On 11/18/2024 the facility Transportation Driver, Maintenance Director and Maintenance Assistant were re-educated by the Regional Maintenance Director on the Facility Vehicle Driver Safety Program, including proper use of wheelchair securement devices ensuring proper tension of devices per manufacturer's instructions, with return demonstration, and competency check off completion, and validated facility Transportation Driver was able to safely operate facility van. This education will be added to the facility orientation program for new Transportation Drivers, Maintenance Director or Maintenance Assistant. This education and competencies will be completed annually for the current Transportation Driver, Maintenance Director and Maintenance Assistant. On 11/18/2024 the Regional Maintenance Director inspected the facility van. The Regional Maintenance Director placed the facility van back in service. The facility Transportation Driver resumed transportation for the facility on 11/19/2024. Alleged Date of Immediate Jeopardy Removal: 11/19/2024 The facility's credible allegation of immediate jeopardy removal was validated on 11/22/24. Observations were conducted of transport drivers securing a wheelchair for transport according to the manufacturer instructions which included securing the tie-down anchors into the floor anchorages and locking them into place. A review of the head-to-toe skin assessments for residents that were transported on the facility van 11/13/24 through 11/15/24 had been completed and no concerns were identified. Interviews conducted with the facility transporters revealed education was provided by the Regional Director of Maintenance which included vehicle driver safety and how to properly secure a resident in the facility van using the 4-point wheelchair securement system per the manufacturer's instructions. The facility transporters also stated they had to verbalize their understanding of the education and complete a return demonstration of how to properly secure a wheelchair in the facility van. An interview conducted with the Regional Director of Maintenance indicated he completed a safety inspection of the wheelchair securement system in the facility van and no concerns were identified. The Regional Director of Maintenance stated he provided education to the facility transporters on how to use the 4-point securement system per the manufacturer's instructions and observations of return demonstrations by the drivers indicated they were able to properly secure a resident in the van. The facility's immediate jeopardy removal date of 11/19/24 was validated on 11/22/24.

Based on observations, record review, and staff, resident, Nurse Practitioner and Pharmacist interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer a monthly dose of Aripiprazole (antipsychotic medication) as prescribed by the physician from July 2024 through November 2024 for 1 of 3 residents reviewed for medication errors (Resident #2). Resident #2 stated she felt like something was wrong a couple of weeks ago because if anyone tried to talk to her, she would break down and cry uncontrollably, even waking up at night with tears running down her face. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included manic depression (bipolar disorder). A Physician order dated 10/18/23 revealed an order for Lithium Carbonate tablet extended release 450 milligram (mg) give one tablet orally at bedtime related to bipolar disorder, current episode manic severe with psychotic features. Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact with no behaviors. Resident #2 did not receive any antipsychotic medication during the assessment period. A Physician order dated 04/16/24 revealed an order for Aripiprazole Intramuscular extended-release suspension prefilled syringe 300 milligram (mg). Inject 300 mg intramuscularly one time a day every 30 days related to bipolar disorder, with episodes of manic severe behaviors and psychotic features. Review of Resident #2's Medication Administration Record (MAR) for July 2024 revealed the medication was scheduled to be administered on 07/15/24 however the block on the MAR was left blank. Review of Resident #2's Medication Administration Record (MAR) for August 2024 revealed the medication was scheduled to be administered on 08/14/24 and was initialed as administered by Nurse #5. On 11/25/24 at 2:43 PM an interview was attempted with Nurse #5 who no longer was an employee of the facility. A return phone call was not received. Review of Resident #2's Medication Administration Record (MAR) for September 2024 revealed the medication was scheduled to be administered on 09/13/24 and was initialed as administered by Nurse #7. On 11/25/24 at 11:10 AM an interview was attempted with Nurse #7 who no longer was an employee of the facility. A return phone call was not received. Review of Resident #2's Medication Administration Record (MAR) for October 2024 revealed the medication was scheduled to be administered on 10/13/24 and was initialed as not administered by coding a 9 on the MAR by Nurse #6. On 11/21/24 at 11:54 AM an interview was conducted with Nurse #6. She stated she documented Resident #2's medication as not administered because it was not in the medication cart or in the medication storage room on the date it was scheduled 10/13/24. The interview revealed the nurses were responsible for a lot of tasks during the day and she was unsure if she had contacted the pharmacy regarding reordering the resident's medication. Nurse #6 stated the typical process for the medication was to reorder it monthly. A reorder involved filling out a reorder form that would be faxed to the pharmacy. She stated she would have removed the sticker from the medication (if it had been available) and placed it onto the form. If the medication was not in the facility the orders could be written on the form and sent to the pharmacy requesting, it to be refilled. Nurse #6 stated she would have passed along the information of the resident's medication not being on the cart to the oncoming nurse for second shift (Nurse #8) so she would know to administer the medication once it arrived from pharmacy. Nurse #6 stated she had not observed Resident #2 crying or having any type of behaviors from not receiving her medication. On 11/22/24 at 11:37 AM an interview was conducted with Nurse #8. Nurse #8 stated she had received report from Nurse #6 on 10/13/24. The interview revealed she did not recall Nurse #6 informing her that Resident #2's medication was not in the facility or that she had not received her intramuscular injection. Nurse #6 stated the medication would not have shown on the MAR for her to administer because at 3:00 PM an entire new set of medication shows up in the computer and the first shift medication would no longer be shown on her screen. She stated she was unaware Resident #2 had not received her medication but had not witnessed the resident having any side effects from not receiving it. The interview revealed the resident seemed to be attending activities in the facility and Nurse #8 had not witnessed the resident crying. Review of Resident #2's Medication Administration Record (MAR) for November 2024 revealed the medication was scheduled to be administered on 11/12/24 and was initialed as administered by Nurse #1. On 11/21/24 at 11:53 AM an interview was conducted with Nurse #1. Nurse #1 stated she had initialed the MAR by mistake on the date of 11/12/24 for Resident #2's medication because she knew the medication was not available and in the facility on that date. She stated she must have just clicked the box as administered on accident and she would correct the MAR. The interview revealed the process for reordering a medication would include faxing a reorder form to pharmacy or calling them. She stated because it was a monthly injection it would have to be reordered on a monthly basis. Nurse #1 indicated the pharmacy was good about sending the medication with the next delivery upon request. The interview revealed she did not reorder the medication on 11/12/24 when she noticed it was unavailable because she stated the nurses had a lot of tasks in the facility and had just forgotten to call the pharmacy. On 11/18/24 at 11:58 AM an interview was conducted with Resident #2. Resident #2 stated she had been having issues not receiving her medication Aripiprazole and she could not recall the last time she had received the medication. She stated she felt like something was wrong a couple of weeks ago because if anyone tried to talk to her, she would break down and cry uncontrollably. Resident #2 indicated she had voiced her concerns to staff in the facility (names she could not recall) but nobody had told her anything about her medication. Resident #2 stated she was feeling a little better now, but she was taking the medication because she was bipolar. She stated she was waking up in the middle of the night with tears running down her face and knew something was wrong. The interview revealed staff would say they were going to check on the medication but would never return to the room. An interview conducted on 11/25/24 at 10:23 AM with the Activities Director revealed Resident #2 often attended activities in the facility and always attended bingo. She stated Resident #2 had been feeling down and depressed within the last several weeks. The Activities Director stated several weeks ago Resident #2 did not attend bingo, which she never misses. She went to the resident's room to see what was wrong and the resident was tearful saying she was feeling depressed, and that something was wrong. The Activities Director stated she notified Social Worker #1 of the incident. On 11/24/24 at 10:36 AM an interview was conducted with Social Worker (SW) #1. During the interview she stated she was notified several weeks ago by the Activities Director that Resident #2 seemed depressed. She stated she went to the resident's room, and she was tearful, stating she felt down and depressed and had been feeling that way for some time. SW #1 stated she reported the information to nursing staff (names she could not recall) but knew SW #2 had seen the resident following her telling the nursing staff the resident was tearful. On 11/21/24 at 3:15 PM an interview was conducted with Social Worker (SW)# 2. SW #2 stated she was part of the psychiatric therapy program and completed talk therapy with the residents in the facility. The interview revealed she had seen Resident #2 on 11/12/24. Resident #2 had reported to her she had bipolar disorder and had recently been waking up crying. Resident #2 reported to SW#2 that she felt her medication was not working and she was experiencing increased anxiety. SW #2 stated she notified Nurse Practitioner #4 after her visit that Resident #2 would be a good person for her to see during her next visit to the facility. On 11/22/24 at 11:10 AM an interview was conducted with Nurse Practitioner (NP) #4. NP #4 stated she was the facility Psychiatric NP and had taken over the role in October 2024. The interview revealed she had not yet seen Resident # 2, however was notified by SW #2 that the resident needed to be evaluated because she had a question about her medication. NP #4 revealed she had seen Resident #2 the week after being told by SW #2. However, the resident stated to her she no longer had a question about her medication. NP #4 stated if Resident #2 was not getting the medication Aripiprazole, a monthly injection then that would explain why she was having episodes of increased crying. NP #4 indicated symptoms of abruptly stopping intramuscular Aripiprazole include crying, mood swings which would be a problem for the resident. The interview revealed that stopping any antipsychotic medication abruptly would be a significant medication error because the medication must be tapered down under medical supervision. Reducing the dosage by 10-50 % over a duration of 1 to 2 weeks or longer. Otherwise, the resident would have symptoms of withdrawal which could include mood swings, crying, insomnia and trouble falling asleep. On 11/22/24 at 11:44 AM an interview was conducted with the Pharmacist. During the interview he stated Resident #2's Aripiprazole Intramuscular for extended-release suspension prefilled syringe 300 milligram (mg) had not been refilled from the pharmacy since 07/15/24. The Pharmacist stated the facility would not have obtained the medication from any other pharmacy. He stated unless the nursing staff placed a reorder form requesting the medication it would not have triggered for them to refill or brought to their attention. The Pharmacist indicated a result of the resident not receiving the medication could have been a psychotic event. He stated the nurses, and physician should be monitoring closely for any symptoms of a psychotic event such as an increase of behaviors. The interview revealed Resident #2 was also receiving an antimanic medication which would have controlled some of her bipolar depression symptoms. On 11/22/24 at 10:58 AM an interview was conducted with the Director of Nursing (DON). The DON stated it was the nurse's responsibility to reorder the medication, the sticker had to be pulled, placed on a reorder sheet and faxed to the pharmacy. She stated she had not heard of any issues with Resident #2's medication. After learning of the missed medication, the DON stated the nurses should have alerted her that the medication was not in the building and called the pharmacy. The DON stated the medication could have been delivered from the pharmacy within 2 to 3 hours if it was placed as a STAT (immediate) order refill. The interview revealed the nurses had not placed an order with pharmacy to have the medication refilled.

Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 4 of 4 residents reviewed for activities (Resident #1, #50, #54, and #85). The residents expressed not being able to leave the facility for over a year made them feel more dependent, less social, sad, and they missed getting out with the group to shop and socialize. The findings included: A review of the June 2024 activity calendar revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility. Observation on 6/17/24 at 9:30 AM revealed the facility was located within a business and residential area that was within driving distance to numerous local and commercial shops, grocery stores, local and commercial coffee shops, fast food, and sit-down restaurants. a. Resident #1 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #1 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #1 was cognitively intact. An interview was conducted with Resident #1 on 6/19/24 at 10:30 AM during resident council meeting revealed there had not been a scheduled group activity outside of the facility in over two years and the resident council had requested one during their monthly activity meetings, and met with the previous administrator about it and each time was told there was nothing they could do because the van was broken, and they had no other way to transport residents. She stated in her opinion group activities outside of the facility were important to the residents that were able to go and participate because it allowed them some lasting independence, socialization with the group and outside world, and helped with their mental and physical health, it made them feel normal and that they weren't just stuck in a facility. Resident #1 stated not being able to leave the facility in several years and participate in group activities outside the facility had sometimes made her feel as though she had lost some of her own independence and was having to rely on someone else to do her personal shopping instead of on her own. She revealed personally being able to do her own shopping and socializing with other people outside of the facility was very important to her and would make her feel more human and like she still had some independence left. b. Resident #50 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #50 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #50 was cognitively intact. An interview was conducted with Resident #50 on 6/19/24 at 10:32 AM during resident council meeting revealed she had been at the facility for the past several years and there had not been a scheduled group activity outside of the facility in over two years. She stated they discussed it with the Activities Director and the previous Administrator and was always told they were not able to schedule activities outside of the facility due to the van being broken, not being able to transport residents, and corporate not approving for any alternate transportation. Resident #50 revealed that going out to eat at a restaurant and socializing or going into a store and being able to touch items and shop for your own personal belongings made you feel independent and normal, and she felt that not being able to do those things over the past several years made her sad, become more reliant on staff and not as social as she used to be and she would just like the opportunity to have those things again. c. Resident #54 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #54 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #54 was cognitively intact. An interview was conducted with Resident #54 on 6/19/24 at 10:34 AM during resident council meeting revealed since he had been to the facility there had been no scheduled activities outside of the facility. He stated during the monthly activities meeting, residents had discussed with the Activities Director and the previous Administrator about scheduling activities outside of the facility and were told that was not possible because the facility was not able to provide transportation due to the van being broken. He revealed not having scheduled activities outside of the facility made him feel sad, depressed, and like he was missing out on the world. Resident #54 stated that he felt like he was more reliant on staff to purchase his personal items for him, and he would like the opportunity to go shopping for himself or to eat at a restaurant and socialize with other people. d. Resident #85 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #85 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #85 was cognitively intact. An interview was conducted with Resident #85 on 6/19/24 at 10:36 AM during resident council meeting revealed since he had been to the facility there had been no scheduled activities outside of the facility. He stated he participated in a monthly activity meeting, and they had discussed with the Activities Director and the previous Administrator on a regular basis about scheduling activities outside of the facility. He revealed they were always told that was not possible because the facility was not able to provide transportation due to the van being broken. Resident #85 stated not having the opportunity to participate in activities outside of the facility made him feel sad, lonely, and like he was losing his independence. He revealed that he felt it was important for residents to have scheduled activities outside of the facility because it allowed them to be able to shop and purchase their own items, maintain their independence, and to be able to socialize with the real world. A telephone interview was conducted with the previous Administrator on 6/19/24 at 2:25 PM revealed he was employed with the facility for the past 2 1/2 years and his last day was on 5/31/24. He stated during the time he worked as the facility Administrator; residents had not been able to participate in scheduled outside of facility activities due to transportation issues. He revealed the facility had two vans but only one of the vans was working, which was used for medical appointments only and corporate would not approve for the other van to be fixed. The previous Administrator stated the Activities Director would speak with him monthly about residents requesting to schedule an activity outside of the facility and he would speak with corporate about fixing the other van or paying for alternate transportation and corporate would not approve for the van to be fixed stating the van was not worth the cost of the repairs and alternate transportation was too expensive. He revealed he did feel that activities outside of the facility were important for residents and allowed them to keep some of their independence and normalcy and he tried to accommodate their requests but without approval from corporate to either fix the other van or pay for alternate transportation, his hands were tied. An interview was conducted with the Activity Director (AD) on 6/20/24 at 9:05 AM revealed she had been working as the AD at the facility for the past 2 years and part of her responsibilities was scheduling and implementing resident activities inside and outside of the facility for each month. She stated since she began working at the facility as the AD, she had not been able to schedule any resident group activities outside of the facility due to transportation issues. She revealed one of the facility vans had been broken since she began working at the facility and she was told by the previous administrator the other facility van could only be used for medical appointments and residents would just have to participate in activities inside of the facility or on facility grounds. The AD stated she had brought the issue to Administration monthly of the residents requesting to schedule activities outside of the facility and each time was told no due to the transportation and alternate transportation for the residents was not available. She revealed she had been doing personal shopping for residents so they could continue to receive their preferences but understood that was not the same as the residents being able to leave the facility and shop for themselves or eat a meal together at a restaurant or watch a movie outside of the facility. She stated she felt like activities outside of the facility for those residents who could participate were important for their overall mental and physical well- being and allowed them some independence. During an interview conducted with the interim Administrator on 6/20/24 at 10:45 AM revealed he began working at the facility on 6/01/24 and was unaware of residents not having been able to participate in activities outside of the facility over the couple of years. He stated he would investigate the issue and see what current and alternative transportation methods were available that could be used to assist the residents being able to participate in activities outside of the facility.

Based on observations, record review, resident, physician, and staff interview the facility failed to protect a severely cognitively impaired resident from the right to be free from physical abuse (Resident #5). Resident #5 experienced physical abuse twice on [DATE] when before bingo Resident #4 placed her arm around the Resident #5's neck, and pulled her forward, and then on the same day, placed Resident #5 in a chokehold with her arm while she was seated in her wheelchair. Resident #5 was held in the chokehold position which caused the resident to gasp and her face to become red. In addition, the facility failed to protect a severely cognitively impaired resident from the right to be free from sexual abuse (Resident #3). Resident #3 experienced sexual abuse on [DATE] when Resident #2 touched and rubbed her pubic area. Based on the reasonable person concept, being placed in a chokehold and non-consensual sexual contact would cause a reasonable person to experience psychosocial harm, trauma and fear from physical or sexual abuse. Abuse occurred for 2 of 4 sampled residents reviewed for protection from abuse (Resident #5 and Resident #3). The findings included: 1. Resident #4 readmitted to the facility on [DATE]. Diagnoses included recurrent major depressive disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. A [DATE] quarterly Minimum Data Set (MDS) assessment evaluated Resident #4 with adequate hearing and vision (with corrective lenses), clear speech, made herself understood, able to understand others, intact cognition, no behaviors, used a motorized wheelchair for mobility and independent or required supervision with activities of daily living (ADL). Review of the care plan for Resident #4 revised [DATE] revealed she did not have a comprehensive person-centered behavior care plan. The care plan did document that Resident #4 required staff assistance with ADL due to her history of PTSD. Staff interventions included allowing rest breaks between tasks, encouraging participation in small tasks, and allowing adequate time to complete tasks. A [DATE] skin audit conducted by the Director of Nursing (DON) recorded no injuries noted for Resident #4. Resident #5 readmitted to the facility on [DATE] and expired in the facility with hospice services on [DATE]. Diagnoses included dementia with agitation, anxiety disorder, mood affective disorder, psychosis, and major depressive disorder. A care plan revised [DATE] recorded Resident #5 cursed at a resident and at staff. Interventions included referral for psych services as needed, provide psych medications as ordered, involve the Responsible Party (RP), if possible, redirect her when she is noted with agitation/aggression, and educate her that cursing others is not acceptable. A [DATE] quarterly MDS assessment evaluated Resident #5 with adequate hearing, impaired vision, clear speech, made self-understood, able to understand others, severely impaired cognition, no behaviors, no functional limitation in upper extremity range of motion (ROM), impaired function limitation in lower extremity ROM on both sides, wheelchair use for mobility and dependent on staff for ADL. A [DATE] skin audit conducted by the DON recorded no injuries noted for Resident #5. 1a. Medical record review for Resident #4 and Resident #5 revealed there was no documentation in either medical record that Resident #4 placed her arms around the neck of Resident #5 on [DATE] and pulled the Resident forward. An interview with the Activity Director (AD) and the Activity Assistant occurred on [DATE] at 5:37 PM. During the interview, the AD stated that on [DATE], she did not know the exact time, but sometime before bingo which was scheduled at 2:30 PM, she was in her office, which was adjacent to the dining room, and she heard Resident #5 talking loudly in the dining room and using profanity. Resident #4 told Resident #5 nobody wants to hear that. During the interview, the Activity Assistant stated that before the 2:30 PM bingo activity, she was not sure of the exact time, she was in/out of the dining room setting up bingo, and she told Resident #5 to calm down. The Activity Assistant stated that Resident #5 got upset, continued using profanity and yelled at Resident #4 b**** I will f*** you up. The Activity Assistant stated she called the AD to come and help her when she saw Resident #5 propel in her wheelchair towards Resident #4, Resident #4 put her arms around the neck/shoulders of Resident #5 and pulled her forward. The Activity Assistant stated she separated the Residents, directed Resident #4 to go to her room while the AD took Resident #5 to the Nurse. The Activity Assistant said she returned to setting up bingo and that she did not report to the administration that she had to separate the two Residents. The interview continued and the AD stated that the Activity Assistant asked for her help. The AD stated that when she came out of her office into the dining room, she saw the Activity Assistant pulling the two residents apart. The AD said that the Activity Assistant told her what occurred, the AD took Resident #5 to her Nurse (Nurse #1), reported the incident to Nurse #1 and returned to the dining room for bingo. The AD stated that she did not report the incident to the administration, but rather took Resident #5 to her Nurse. Both the AD and the Activity Assistant stated they were unaware that a second incident occurred between Resident #4 and Resident #5 on the same day ([DATE]) in the hallway. Nurse #1 was interviewed via phone on [DATE] at 3:35 PM. He stated that he was the assigned Nurse on the South Unit for the 7A - 3P shift on [DATE]. He stated that close to the end of the shift on [DATE] he heard staff stating that Resident #5 said something to Resident #4 that got her upset and caused her to hit Resident #5. He stated that no one reported the incident to him directly. Nurse #1 said he was told that an incident report had been made, but he could not recall who told him that, so he did not make a report about the incident because he did not witness it and he was not asked to do any follow up. Nurse #1 said after he heard about the incident, he did recall seeing Resident #5 in her wheelchair at the end of the hall near her room, but that she did not mention what occurred. Nurse #1 said he was not made aware that there were two incidents between Resident #4 and Resident #5 that day. Nurse #1 stated that if staff had reported the incident directly to him, he would have contacted the DON and Administrator to get the police involved if a resident was assaulted and followed the facility's abuse policy. Nurse #1 described Resident #5 as confused intermittently and heard staff say she made racial comments and cursed staff/resident, but that he was not aware that Resident #5 ever physically hit another resident. Nurse #1 described that Resident #4 seemed like the sweetest person, but that she could be aggressive at times and made verbal threats of what she would do in different circumstances if she were provoked. He stated that he never reported the behavior of Resident #4 because these were comments that he heard in passing. 1b. A Resident Incident Report for Resident #4 completed by the DON recorded that on [DATE] at 1:45 PM, Resident #4 and Resident #5 were both in the dining room when Resident #5 began to harass the kitchen staff. The report recorded that when Resident #4 told Resident #5 to stop harassing the staff, Resident #5 turned to Resident #4 and cursed at her. At this, Resident #4 stated that she got upset and put Resident #5 in a chokehold because Resident #5 had been harassing her for weeks. The report recorded that staff heard the commotion, separated the Residents, and both Residents were assessed by the DON without injury. The report recorded that the Physician (MD), RP for Resident #5, law enforcement and Adult Protective Services (APS), were notified of the incident. Review of a Facility Reported Incident, completed by the DON, dated [DATE] at 1:45 PM indicated Resident #4 put Resident #5 in a headlock. The Summary of Facility Investigation recorded, Resident #4 and Resident #5 were both in the dining room when Resident #5 shouted to dietary staff that she was hungry. The DON recorded Resident #5 received a sandwich and juice but continued to shout for more food. Resident #4 asked Resident #5 to stop harassing the dietary staff at which time Resident #5 turned to Resident #4 and responded with expletives. The DON documented that Resident #4 stated that she became extremely frustrated because Resident #5 had been harassing her for weeks, and that this incident made her so angry that she rolled up behind Resident #5 and put her in a headlock from behind. A police report dated [DATE] at 2:08 PM recorded that Resident #4 verbally threatened Resident #5 with bodily injury. Resident #5 alleged that Resident #4 threatened to choke her to death. Multiple attempts to interview the police officer were unsuccessful. A Nursing General Note for Resident #5 dated [DATE] at 8:38 AM by the DON recorded that on [DATE] at approximately 1:45 PM, Resident #5 and Resident #4 were in the dining room. The DON recorded that Resident #4 reported that Resident #5 started harassing kitchen staff and when Resident #4 asked Resident #5 to stop harassing the kitchen staff, Resident #5 cursed at her. At this, the DON recorded that Resident #4 stated that she got upset and put Resident #5 in a chokehold because Resident #5 had been harassing her for weeks. The DON recorded that staff heard the commotion and separated the Residents. The RP for Resident #5 was made aware of the incident and the incident was recorded in the MD communication book. During an interview with Resident #4 on [DATE] at 10:30 AM, and a follow-up interview on [DATE] at 9:15 AM, she stated that on [DATE], she remembered that she and Resident #5 were in the dining room. Resident #4 said she recalled Resident #5 kept messing with staff in the kitchen saying she was hungry. Resident #4 said she told Resident #5 to leave the kitchen staff alone and to eat the food she had been given. At that time, Resident #5 turned to her, got in her face, and said f*** you. Resident #4 said she got so tired of Resident #5 talking to her that way, so she knocked on the activity door, which was a room in the dining room, but then decided she would go find a staff member. Resident #4 stated that as Resident #5 was leaving the dining room Resident #4 stated, she rolled up behind her (Resident #5) in the hallway and stated, that's when I blacked out and then the next thing I knew staff told me that I grabbed her around her neck and was pulling her hair. Resident #4 stated that staff had to tell her what she did when she blacked out because she did not remember that she grabbed Resident #5 around her neck and pulled her hair. She stated staff also told her that on the same day, [DATE], there was another incident between the two Residents that occurred before she grabbed Resident #5 around her neck. Resident #4 said the Activity Assistant told her that while the two Residents were in the dining room before bingo, the Activity Assistant had to separate them because Resident #4 placed her arms around the neck of Resident #5 and pulled her forward. Resident #4 stated she did not recall putting her arms around the neck of Resident #5 and pulling her forward, but that Resident #5 must have continued to curse at her in order for her to physically assault Resident #5 twice. Resident #4 stated this was not her usual behavior, she stated I don't put my hands on people, and I asked God to forgive me for what I did. She stated that she did not have a chance to apologize to Resident #5 before she passed away and that she felt bad about that, but that Resident #5 should not have gotten in her face and cursed at her. Resident #4 stated that she talked to a Mental Health Nurse Practitioner after these incidents, who adjusted her medications for depression, which has helped. The Human Resources (HR) Director was interviewed on [DATE] at 1:20 PM and stated that on [DATE] she was in the DON's office sometime after lunch, she did not recall the exact time, when she heard Resident #4 say I told you not to f*** with me no more. When she went into the hallway, she saw Resident #4 and Resident #5 in the hallway in front of the dining room. The HR Director described that Resident #4's arm was around the neck of Resident #5, in a headlock, Resident #5's face was red, and she was gasping. The HR Director stated she told Resident #4 to let go of Resident #5, but she did not, so the HR Director had to physically separate them. The HR Director stated that the DON came into the hallway after the incident, so she reported to the DON what happened and called the Administrator to report to him what occurred. An interview on [DATE] at 5:30 PM occurred with the DON. She stated that she was notified on [DATE] by the HR Director that at around 1:45 PM, the HR Director overheard commotion coming from the hallway near the dining room. The HR Director said she went to the hallway and saw Resident #4 holding Resident #5 in a headlock. The HR Director said she separated the Residents, and Resident #5 was taken to her room. The DON stated she notified the Administrator, started an investigation, contacted law enforcement, and the RP for Resident #5. The DON said she assessed and interviewed both Residents. Resident #4 was assessed without injury and when she was interviewed, she explained she was tired of Resident #5 picking on her and this is what she gets. The DON said that about an hour later, Resident #4 came to her office, very remorseful and said she should not have choked Resident #5 but reported her concerns regarding Resident #5 to staff instead. She said that she just lost it. Resident #4 said that Resident #5 picked on her for weeks and she was tired of it. She stated that while the Residents were in the dining room, Resident #5 started banging on the kitchen door, asking for food. The kitchen staff gave her a sandwich and juice, but Resident #5 continued to yell out for more food. Resident #4 said she told Resident #5 to stop shouting and to eat the food she had. That's when Resident #5 cursed at her, so Resident #4 went up to Resident #5 and put her in a headlock. The DON stated that Resident #5 was assessed without injury, but during the assessment, she was still upset and cursing, so the DON had to allow her time to calm down. When Resident #5 was interviewed, she said that Resident #4 tried to choke her, but that she was fine. The DON said that both Residents were monitored every 15 minutes for two hours and then hourly for the next 24 hours. During the interview, the DON was asked by the Surveyor if she was aware that on [DATE] sometime before bingo, the Activity Assistant separated Resident #4 from Resident #5 in the dining room when she put her arms around the neck of Resident #5 and pulled her forward. The DON stated that she was not notified by staff that both Residents were separated earlier that day on [DATE] due to another physical altercation that occurred in the dining room. She said that if she had been made aware of the first physical altercation that occurred between the two Residents in the dining room, she would have separated the Residents then which would have prevented the second incident from occurring later in the hallway. The Administrator stated in an interview on [DATE] at 5:45 PM that he was notified on [DATE] that Resident #4 physically assaulted Resident #5 in the hallway after an argument occurred in the dining room. He stated that he told the staff to separate the Residents, assess them for injury, place the Residents on monitoring every 15 minutes for the first two hours and then hourly checks thereafter. He also informed staff to notify law enforcement, the MD, the RP for Resident #5, and APS. The Administrator stated that when he returned to work on [DATE], he spoke to Resident #4 about her behavior and advised her that she should have reported her previous concerns with Resident #5 to the DON, that her behavior was unacceptable and that he expected to see improvement. Resident #4 stated that she understood what she did wrong and that her behavior needed to improve. He stated that at the time of the incident, Resident #4 was being followed weekly by mental health services for depression and after the physical abuse toward Resident #5, she was referred for psych services. He said that he was not notified of a prior incident involving physical abuse by Resident #4 to Resident #5 on the same day. He stated that he expected residents to be protected from abuse and if he had been notified of the first incident of physical abuse by Resident #4 that occurred in the dining room, he would have strategized a plan to prevent further interactions between the two Residents and protected Resident #5 from further abuse. A phone interview with the MD occurred on [DATE] at 9:06 AM. The MD stated that she was notified that Resident #4 physically assaulted Resident #5 on [DATE] and that she remembered the incident vaguely. The MD stated she recalled Resident #4, physically assaulting other residents was not her history and such an incident had not occurred before with Resident #4. The MD stated both Residents were separated, both Residents were assessed without injury and assessed for any contributing factors that attributed to the events of [DATE]. The MD stated that Resident #4 was already followed by mental health services for a history of depression and when this occurred, she was referred for psych services. The MD stated that to her knowledge, Resident #4 had no further incidents of physical assault. The facility put ongoing monitoring into place for both Residents and the family of Resident #5 did not want to press charges. MD stated that the facility had a responsibility to protect all residents in the facility and due to the facility's high-risk population of residents with a mental health/behavior history, that made managing behaviors difficult. The MD stated that she was no longer the MD at the facility, but while she was the MD, the facility met the mental health needs of the residents by making mental health services readily available. 2. Resident #2 was admitted to the facility on [DATE] from a previous nursing home with diagnoses that included other sexual dysfunction not due to a substance or known physiological condition, dementia, mild with other behavioral disturbance, cerebrovascular accident with hemiplegia affecting the left non-dominant side, anxiety disorder, depression, and adjustment disorder with depressed mood. The February 2024 Medication Administration Record (MAR) for Resident #2 recorded a Physician (MD) order for Fluoxetine Hydrochloride (Prozac) 20 milligrams (mg) to give one tablet once daily for depression. The medication start date was [DATE]. A [DATE] Psychotherapy Diagnostic Assessment written by the Licensed Clinical Social Worker (LCSW) recorded Resident #2 displayed inappropriate sexual behaviors as noted in a previous assessment completed by the Psych Mental Health Nurse Practitioner (PMHNP) in a previous nursing home. The assessment also noted that Resident #2 met the criteria for adjustment disorder due to impulsivity and inappropriate sexual behaviors. A phone interview with the LCSW occurred on [DATE] at 11:08 AM. She stated that her initial visit with Resident #2 occurred on [DATE] for Psychotherapy Talk Services. She stated that he was referred to mental health services regarding his diagnoses of adjustment disorder and mild dementia with other behavioral disturbance. The LCSW said during her initial assessment on [DATE], he did not seem oriented and appropriate for services due to some confusion. The LCSW said she reviewed the progress notes of his history from the psych services he received while he was a Resident at the previous nursing home. The LCSW said she saw in the notes that he was accused by two female residents of inappropriately touching them, presented with mild cognitive impairment during his stay at the previous nursing home and received Prozac 20 mg daily to assist with sexual behaviors by decreasing his libido (sexual desire). The LCSW said she communicated to the Administrator that Resident #2 had a history of inappropriate touching while he was a Resident at the previous nursing home and that the electronic psych records from the previous nursing home were faxed to the facility. A [DATE] psychiatric initial consult progress note written by the Doctor of Nurse Practitioner, (DNP) recorded that Resident #2 was referred for mild dementia with other behavioral disturbance and other sexual dysfunction not due to a substance or known physiological condition. The DNP documented that she reviewed the prior psych records from the previous nursing home which indicated Resident #2 displayed inappropriate sexual behaviors when he was noted touching another female resident, but that he had not been noted to display any current sexual behaviors at the facility. The DNP documented that the Administrator informed her of a conversation he had with Resident #2 regarding his behaviors at the previous nursing home and advised that those types of behaviors were not allowed in the facility under any circumstances. The DNP recommended to continue Prozac 20 mg daily. The DNP was interviewed by phone on [DATE] at 8:07 AM. She stated that Resident #2 was admitted to the facility from the previous nursing home where he received psych services with the same provider group. The DNP said she had access to his prior psych records because the psych services were from the same provider group. She stated that when she reviewed his previous psych records she noted his history of inappropriate sexual behavior, which she spoke to the Administrator about on [DATE]. The DNP said Resident #2 was placed on Prozac 20 mg when he exhibited inappropriate sexual behaviors at the previous nursing home. The DNP said she had a very candid conversation with Resident #2 on her first visit with him on [DATE], regarding his behavior at the previous nursing home and he was informed that inappropriate sexual behavior was not going to be tolerated at the facility. A [DATE] admission Minimum Data Set assessed Resident #2 with adequate hearing, adequate vision, clear speech, understood by others, and understands others, intact cognition, no mood disorders, no behaviors, no functional limitation in upper/lower extremity range of motion (ROM), and he independently used a manual wheelchair for ambulation. Review of the [DATE] care plan for Resident #2 revealed he did not have a behavior symptoms care plan. During an interview on [DATE] at 3:00 PM, Resident #2 said a few days after he came to the facility, he told the Administrator and Director of Nursing (DON) about the time he touched (named Resident) at the previous nursing home. Resident #2 said They asked me if I had touched anyone inappropriate at (the previous nursing home) and I told them I touched her breast, she said I could, but the Administrator told me not to do that here, I told him that I would try to be good here, he said I had to behave and that I could not touch anyone here. During an interview with the Administrator and DON on [DATE] at 1:45 PM, the Administrator said the LCSW notified him after her first session with Resident #2 on [DATE] that she had access to the psych progress notes for Resident #2 from the previous nursing home since Resident #2 was seen by a Practitioner from the same provider group. Per the Administrator, the LCSW said when she reviewed the psych progress notes from the previous nursing home, she saw documentation that Resident #2 had poor, inappropriate behaviors at the previous nursing home that required one-to-one monitoring. The Administrator stated that the LCSW was not specific about the behaviors, and that he did not ask specifics, but that the Administrator and the DON went to Resident #2 and asked him what happened. The DON said when interviewed, Resident #2 said that he tried to fist bump two residents and accidentally contacted their shoulder, and then he said, I did not touch anyone. The Administrator stated he advised Resident #2 of the expectation to have appropriate behavior while he was a Resident at the facility, Resident #2 expressed understanding. The Administrator stated that he did not request the psych notes from the previous nursing home at that time. Resident #3 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depressive disorder, and dementia without behavioral disturbance. A [DATE] quarterly MDS assessed Resident #3 with severely impaired cognition, dependent on staff for all activities of daily living (ADL) and used a wheelchair for ambulation. Resident #1 was admitted to the facility on [DATE] and discharged home on [DATE]. A [DATE] quarterly MDS assessment indicated Resident #1's cognition was intact. A [DATE] Facility Reported Investigation for resident abuse recorded that on [DATE] at 4:40 PM, staff notified nurse leadership of poor resident interaction that was witnessed by Resident #1. The Summary of Investigative Findings recorded that on [DATE], Resident #1 witnessed Resident #2 touch Resident #3 on the leg while the Residents were seated in the commons area of the [NAME] Unit. Resident #1 yelled for Resident #2 to stop touching the leg of Resident #3 which prompted staff to separate Resident #2 from Resident #3. Resident #2 was placed on one-to-one monitoring ongoing, Resident #3 was assessed without injury, and notifications were made to the Administrator, law enforcement, Adult Protective Services (APS), the Responsible Party (RP) for Resident #3, the Emergency Contact for Resident #2, and the MD. The Summary of Findings included a written statement from Resident #1 which recorded I, (Name of Resident), saw the young man put his hands between a resident's legs, the resident was trying to move his hands, but he continued to rub her between her legs or crotch; I saw it and approached him telling him to stop because it was wrong. A [DATE] police report noted that law enforcement was notified at 5:03 PM on [DATE] that the listed suspect (name withheld) sexually assaulted the victim (name withheld) at the facility on [DATE] at approximately 5:00 PM. The North Carolina Offense Category was listed as adult sex offense/assault/sexual battery, and the classification was listed as forcible fondling. Attempts to interview law enforcement were unsuccessful. A [DATE] 11:34 AM Triage Note from the DON to DNP recorded that on [DATE], Resident #2 was caught fondling a female resident who was oriented to self only due to dementia, the Resident (Resident #2) was placed on one-to-one since then, he is on Prozac for depression, please advise. The DNP responded on [DATE] to the Triage Note from the DON that Resident #2 was not on Prozac for depression, but for his history of inappropriate sexual behavior, to refer to the DNP progress note of [DATE], increase Prozac to 40 mg daily and under no circumstances leave Resident #2 alone with Resident #3. A [DATE] Resident Incident Report for Resident #3 recorded that on [DATE] at 5:00 PM, Resident #3 was seated in her wheelchair when Resident #1 screamed get away from her when she saw Resident #2 put his hands between the legs of Resident #3. The report recorded that Resident #3 began moving the hands of Resident #2, but Resident #2 continued rubbing the Resident's leg. The report described Resident #3 as alert to person only, the Immediate Action Taken as staff separated and monitored the two Residents, and the MD and RP for Resident #3 were notified. A [DATE] Resident Incident Report for Resident #2 recorded that on [DATE] at 5:38 PM, Resident #1 yelled What are you doing at Resident #2 and accused him of rubbing Resident #3 between her legs. The Resident Incident Report described Resident #2 as alert, oriented to person, place, and time. The Immediate Action Taken recorded Resident #2 was sent to the emergency room (ER) for a psych evaluation and returned to the facility before midnight with no new orders. The Administrator, MD and Emergency Contact for Resident #2 were notified of the incident. During review of the [DATE] Resident Incident Report for Resident #2, with the Administrator on [DATE] at 12:30 PM, he stated that the date of [DATE] was an error and should have been [DATE]. The medical record for Resident #2 included progress notes from the previous nursing home faxed to the facility on [DATE] at 10:02 AM which included the following: - A Triage Note dated [DATE] recorded Resident #2 inappropriately touched another resident's breast and the staff requested medication management. - A Physician Assistant (PA) progress note dated [DATE], recorded the PA was asked to assess Resident #2 for sexual behavior issues due to complaints by staff of inappropriate gestures and touching. The progress note recorded a MD order was written for a psych referral and for Prozac 20 mg daily. - A Psych Mental Health Nurse Practitioner (PMHNP) progress note dated [DATE], recorded Resident #2 was seen for an urgent Telehealth psych evaluation for the diagnoses of mild dementia, with other behavioral disturbance and other sexual dysfunction not due to a substance or known physiological condition after accusations from two female residents of inappropriately touching them. The progress note recorded that Resident #2 reported to the PMHNP when interviewed that he accidently touched a female resident. The progress note recorded that the Resident was placed on Prozac 20 mg daily after this incident to assist with sexual behaviors by reducing his libido. A [DATE] psychotherapy progress note written by the LCSW recorded that staff reported that on [DATE], Resident #2 displayed inappropriate sexual behaviors. The progress note recorded that Resident #2 acknowledged during the [DATE] psychotherapy session that he inappropriately touched a resident, made hand motions towards his private area when asked where he touched the resident and stated that the resident said he could. The note also recorded that Resident #2 stated that he was being kept in his room, but that he did not want to stay there when he referred to the one-on-one support provided by the facility because of his inappropriate behavior. The progress note recorded that he expressed he understood that he should not ask other peers to be touched inappropriately as some residents may not have the cognition to consent appropriately. The progress note recorded Resident #2 received Prozac 40 mg daily to decrease libido and manage his sexual behaviors. Resident #2 was interviewed on [DATE] at 1:00 PM. He stated that he was recently admitted to the facility and that since his admission, staff spoke to him about touching a resident. Resident #2 said he touched a resident on her vagina while she was clothed. When asked to show the surveyor where he touched the Resident, he touched the center of his pubic area and said, I touched her here, I asked her if I could touch her, and she said yes. He said they were in the TV area watching TV near the nurse's station when he touched Resident #3. Then he said, But then (named Resident #1) yelled at me to stop, I told her what is it to you, nobody is touching you, but she told on me, so I am supposed to be going to court so [NAME] can get guardianship of me. A [AGE] year-old with a guardian, what do I need a guardian for? Now I have a sitter with me all the time. It's like I am a chap. When asked if anything like this happened before he said yeah, I had a sitter while I was at a (previous nursing home), I touched a lady there, I asked her too and she said I could, but then I got in trouble and had to be watched. Resident #3 was interviewed on [DATE] at 1:19 PM and did not recall the sexual abuse that occurred on [DATE]. The Medication Aide (MA) was interviewed on [DATE] at 4:22 PM and stated she was the assigned MA on [DATE] on the [NAME] Unit. The MA s [TRUNCATED]

Based on a resident interview, staff interviews and record review, the facility failed to report an incidence of physical abuse to facility administration to protect a resident from further physical abuse. Resident #5 experienced physical abuse twice on 12/27/23. Both incidents occurred on 12/27/23 before 2:30 PM. Resident #4 first physically assaulted Resident #5 in the dining room. This occurrence of physical abuse was not reported to the facility administration. As a result, Resident #4 physically assaulted Resident #5 again in the hallway. The deficient practice occurred for 1 of 4 sampled residents reviewed for abuse (Resident #5). The findings included: The facility's policy, Abuse Prevention, Intervention, Reporting and Investigation, effective November 2016, recorded in part, The facility will ensure the protection, prompt reporting, and interventions in response to alleged, suspected, or witnessed abuse of any resident. It is the responsibility of employees to promptly report to facility management any incident or suspected incident of abuse from other residents, staff, family, or visitors. Residents are to be protected during incident investigations by ensuring the administrator is immediately informed. A resident who is allegedly mistreated by another resident is removed from contact with that resident during the investigation. It is the facility policy that residents will be protected from alleged offender(s). Resident #5 readmitted to the facility on [DATE]. Diagnoses included dementia with agitation, anxiety disorder, mood affective disorder, psychosis, and major depressive disorder. Resident #4 readmitted to the facility on [DATE]. Resident #4 was her own responsible party (RP). Diagnoses included recurrent major depressive disorder, post-traumatic stress disorder, and anxiety disorder. Review of a Facility Reported Incident completed by the Director of Nursing (DON) and dated 12/27/23 at 1:45 PM indicated Resident #4 and Resident #5 were both in the dining room when Resident #5 shouted to dietary staff that she was hungry. Resident #5 received a sandwich and juice but continued to shout for more food. Resident #4 asked Resident #5 to stop harassing the dietary staff at which time Resident #5 turned to Resident #4 and responded with expletives. Resident #4 stated that she became extremely frustrated because Resident #5 had been harassing her for weeks, and that this incident made her so angry that she rolled up behind Resident #5 in the hallway and put her in a headlock from behind. A Resident Incident Report for Resident #5 completed by the DON recorded that on 12/27/23 at 1:45 PM, Resident #4 and Resident #5 were both in the dining room when Resident #5 began to harass the kitchen staff. When Resident #4 told Resident #5 to stop harassing the staff, Resident #5 turned to Resident #4 and cursed at her. At this, Resident #4 stated that she got upset and put Resident #5 in a chokehold in the hallway, witnessed by the Human Resources (HR) Director, because Resident #5 had been harassing her for weeks. The Resident Incident Report documented that Resident #5 was assessed by the DON without injury. The Resident Incident Report did not record that a second incident of physical abuse by Resident #4 against Resident #5 also occurred on 12/27/23 before 2:30 PM. A Nursing General Note dated 12/28/23 at 8:38 AM by the DON recorded that on 12/27/23 at approximately 1:45 PM, Resident #5 and Resident #4 were in the dining room. Resident #4 reported that Resident #5 started harassing kitchen staff and when Resident #4 asked Resident #5 to stop harassing the kitchen staff, Resident #5 cursed at her. At this, Resident #4 stated that she got upset and put Resident #5 in a chokehold because Resident #5 had been harassing her for weeks. Staff heard the commotion and separated the Residents. The Nursing General Note recorded that Resident #5 was assessed without injury. The Nursing General Note dated 12/28/23 did not record that a second incident of physical abuse by Resident #4 against Resident #5 also occurred on 12/27/23 before 2:30 PM. During an interview with Resident #4 on 4/11/24 at 10:30 AM, and a follow-up interview on 4/12/24 at 9:15 AM, she stated that on 12/27/23, she remembered that she and Resident #5 were in the dining room sometime before bingo which was scheduled for 2:30 PM, when Resident #5 kept messing with staff in the kitchen saying she was hungry. Resident #4 said she told Resident #5 to leave the kitchen staff alone and to eat the food she had been given. At that time, Resident #5 turned to her, got in her face, and said f*** you. Resident #4 said she got so tired of Resident #5 talking to her that way, so she knocked on the activity door, which was an office inside the dining room, but then decided she would go find a staff member. Resident #4 stated that as Resident #5 was leaving the dining room Resident #4 stated, she rolled up behind her (Resident #5) in the hallway and stated, that's when I blacked out and then the next thing I knew staff told me that I grabbed her around her neck and was pulling her hair. Resident #4 stated that staff had to tell her what she did when she blacked out because she did not remember that she grabbed Resident #5 around her neck and pulled her hair. She stated staff also told her that on the same day, 12/27/23, there was another incident between the two Residents that occurred before she grabbed Resident #5 around her neck. Resident #4 said the activity assistant told her that while the two Residents were in the dining room before bingo, the activity assistant had to separate them because Resident #4 placed her arms around the neck of Resident #5 and pulled her forward. Resident #4 stated she did not recall putting her arms around the neck of Resident #5 and pulling her forward, but that Resident #5 must have continued to curse at her in order for her to physically assault Resident #5 twice. Resident #4 stated this was not her usual behavior, she stated I don't put my hands on people, and I asked God to forgive me for what I did. She stated that she did not have a chance to apologize to Resident #5 before she passed away and that she felt bad about that, but that Resident #5 should not have gotten in her face and cursed at her. Resident #4 stated that she talked to a mental health nurse practitioner after these incidents, who adjusted her medications for depression, which has helped. An interview with the Activity Director (AD) and the Activity Assistant occurred on 4/11/24 at 5:37 PM. During the interview, the AD stated that on 12/27/23, she did not know the exact time, but sometime before bingo which was scheduled at 2:30 PM, she was in her office, which was a room inside the dining room, and she heard Resident #5 talking loudly in the dining room and using profanity. Resident #4 told Resident #5 nobody wants to hear that. During the interview, the Activity Assistant stated that before the 2:30 PM bingo activity, she was not sure of the exact time, she was in/out of the dining room setting up bingo, and she told Resident #5 to calm down. The Activity Assistant stated that Resident #5 got upset, continued using profanity and yelled at Resident #4 b**** I will f*** you up. The Activity Assistant stated she called the AD to come and help her when she saw Resident #5 propel in her wheelchair towards Resident #4, Resident #4 put her arms around the neck/shoulders of Resident #5 and pulled her forward. The Activity Assistant stated she separated the Residents, directed Resident #4 to go to her room while the AD took Resident #5 to her room. The Activity Assistant said she returned to setting up bingo and that she did not report to administration that she had to separate the two Residents. The interview continued and the AD stated that the Activity Assistant asked for her help. The AD stated that when she came out of her office into the dining room, she saw the Activity Assistant pulling the two residents apart. The AD said that the Activity Assistant told her what occurred, the AD took Resident #5 to her nurse (Nurse #1), reported the incident to Nurse #1 and returned to the dining room for bingo. The AD stated that she did not report the incident to the administration, but rather took Resident #5 to her Nurse. Nurse #1 was interviewed via phone on 4/12/24 at 3:35 PM. He stated that he was the assigned Nurse on the South Unit for the 7A - 3P shift on 12/27/23. He stated that close to the end of the shift on 12/27/23 he heard staff stating that Resident #5 said something to Resident #4 that got her upset and caused her to hit Resident #5. Nurse #1 said he was told that an incident report had been made, but he could not recall who told him that, so he did not make a report about the incident because he did not witness it and he was not asked to do any follow up. Nurse #1 said after he heard about the incident, he did recall seeing Resident #5 in her wheelchair at the end of the hall near her room, but that she did not mention what occurred. Nurse #1 said he was not made aware that there were two incidents between Resident #4 and Resident #5 that day. Nurse #1 stated that if staff had reported the first incident directly to him, he would have contacted the DON and administrator to get the police involved if a resident was assaulted and followed the facility's abuse policy to protect Resident #5 from further physical abuse. The Human Resources (HR) Director was interviewed on 4/11/24 at 1:20 PM and stated that on 12/27/23 she was in the DON's office sometime after lunch, she did not recall the exact time, when she heard Resident #4 say I told you not to f*** with me no more. When she went into the hallway, she saw Resident #4 and Resident #5 in the hallway in front of the dining room. The HR Director described that Resident #4's arm was around the neck of Resident #5, in a headlock, Resident #5's face was red, and she was gasping. The HR Director stated she told Resident #4 to let go of Resident #5, but she did not, so the HR Director had to physically separate them. The HR Director stated that the DON came into the hallway after the incident, so she reported to the DON what happened and called the administrator to report to him what occurred. The HR Director stated that she was not aware of a second incident of physical abuse by Resident #4 towards Resident #5 that occurred in the dining room. An interview on 4/11/24 at 5:30 PM occurred with the DON. She stated that she was notified on 12/27/23 by the HR Director that at around 1:45 PM, the HR Director overheard commotion coming from the hallway near the dining room. The HR Director said she went to the hallway and saw Resident #4 holding Resident #5 in a headlock. The HR Director said she separated the Residents, and Resident #5 was taken to her room. The DON stated she notified the administrator and started an investigation. The DON said that both Residents were monitored every 15 minutes for two hours and then hourly for the next 24 hours. During the interview, the DON was asked by the surveyor if she was aware that on 12/27/23 sometime before bingo, the activity assistant separated Resident #4 from Resident #5 in the dining room when she put her arms around the neck of Resident #5 and pulled her forward. The DON stated that she was not notified by staff that both Residents were separated earlier that day on 12/27/23 due to another physical altercation that occurred in the dining room before bingo. She said that if she had been made aware of the first physical altercation that occurred between the two Residents in the dining room, she would have separated the Residents then which would have prevented the second incident from occurring later in the hallway. The Administrator stated in an interview on 4/11/24 at 5:45 PM that he was notified on 12/27/23 by the DON that Resident #4 physically assaulted Resident #5 in the hallway after an argument occurred in the dining room. He stated he did not recall the exact time he was notified. He stated that he told the staff to separate the Residents, assess them for injury, place the Residents on monitoring every 15 minutes for the first two hours and then hourly checks thereafter. When asked by the Surveyor if he was aware that two incidents of physical abuse occurred on 12/27/23 between the two Residents, he said that he was not notified of a prior incident involving physical abuse by Resident #4 to Resident #5 on the same day. He stated that he was only aware of the physical abuse by Resident #4 that occurred in the hallway. He stated that he expected residents to be protected from abuse and if he had been notified of the first incident of physical abuse by Resident #4 that occurred in the dining room, he would have strategized a plan to prevent further interactions between the two residents and protected Resident #5 from further abuse that occurred in the hallway. The Administrator and the DON were notified of immediate jeopardy on 4/12/24 at 2:05 PM. The facility provided the following corrective action plan with a completion date of 12/29/23. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 12/27/23 during the 7a - 3p shift, the Activity Director reported to nursing that Resident #4 placed both arms around the neck/shoulder area of Resident #5, a confused resident, and pulled Resident #5 towards her when she was approached by Resident #5 in the dining room after a verbal altercation between the two Residents. This resident-to-resident altercation was not reported to the administration, and therefore protection was not put into place or implemented. On 12/27/2023, at approximately 1:45pm, Resident # 4 was sitting in the facility's dining room in her wheelchair when a staff member brought Resident #5 into the dining room. Resident # 5 proceeded to shout that she was hungry to get the attention of the kitchen staff. A sandwich and juice were brought to the resident, but the resident continued to shout out after the kitchen staff went back into the kitchen and closed the door. Resident #4 then asked Resident #5 to stop harassing the kitchen staff and eat the food that was brought to her. On hearing what Resident #4 stated, Resident #5 turned around and uttered expletives to Resident #4. Resident #4 explained that when she heard the expletives, she was extremely frustrated because Resident #5 has been harassing her for weeks and this incident made her get so angry that she rolled up to Resident #5 and put her in a headlock from behind. Staff members outside the dining room heard the commotion and ran in to separate the two residents. The residents were separated by the Human Resources (HR) Manager. Resident #5 was examined by the Director of Nursing for any injuries. No injuries were noted, and the resident was taken to her room while Resident #4 was allowed to remain in the dining room. The facility's Nurse Practitioner was informed of the incident on 12/27/2023. Law Enforcement was notified on 12/27/2023 and Adult Protective Services (APS) was notified on 12/27/2023. Resident #4 is her own Responsible Party. Resident #5's Responsible Party was notified. Resident # 4 was placed on Q15mins every 15 minutes) checks for 2hrs (hours) and then Q1hr for the next 24 hrs on 12/27/2023. No aggressive behavior was observed during the observation period. Resident #4's next psych visit was 1/9/2024. No changes were made to the medications. Progress notes states that the resident will have follow up in one month. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 12/27/2023 abuse questionnaires were completed by the facility's Social Worker on all residents with Brief Interview for Mental Status (BIMS) score of 9 and above with no adverse responses to determine if any other residents had any unidentified allegations of abuse that had not been reported. The questions included with Social Worker Assistant's interviews with residents were the following: 1. Have you had inappropriate interactions with others that was uncomfortable? i.e. personal space was crossed with another resident. If so, describe specifically your encounter in detail. 2. Have you observed poor interactions from residents on your unit toward others, if so, describe your observation. Based on resident interviews there were no other reported incidents of abuse from any residents. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing educated current facility staff on the facility abuse policy. Education was completed on 12/27/2023. Education included but not limited to the various types of abuse such as physical, mental, sexual, neglect, misappropriation of property, and involuntary seclusion. Education is also inclusive of the procedure for reporting any observed or suspected events of abuse. Education also included the importance of protecting residents following an allegation of abuse. Staff will not be permitted to work until education is completed. The Director of Nursing will verify completion of education. Education will be included in new hires orientation by Human Resources as of 12/28/2023. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing/Unit Managers will audit progress notes and incident reports during clinical meetings beginning on 12/27/23 to ensure any behaviors or altercations between residents were reported to administrator and/or Director of Nursing. Auditing will be completed 5 x per week for 4 weeks then weekly for 4 weeks starting on 12/27/2023. The Director of Nursing will report all findings of audits to the Quality Assurance Performance Improvement committee monthly until substantial compliance is obtained. Facility completed AdHoc QAPI to review investigation and current action plan to ensure all components were done and followed on 12/27/2023. IJ removal date: 12/29/2023 On 4/29/24 the facility's credible allegation of immediate jeopardy removal date of 12/29/23 was validated. The validation was evidenced by interviews with staff and residents, record review, and review of in-service agendas and staff attendance records. In-service agendas and staff attendance records revealed staff were in-serviced on the facility's Abuse, Prevention, Intervention, Reporting, and Investigation policy, effective November 2016, One on One Monitoring and updating the care guide. Interviews conducted with staff from all shifts and all disciplines, and interviews conducted with residents indicated knowledge of the in-services provided. Review of QA records, monitoring tools and audits revealed ongoing monitoring systems were in place by the facility.

Based on observation, record reviews and resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to protect residents' rights to be free from physical and/or emotional abuse for 4 of 4 residents sampled. The abuse occurred on 4 separate occasions. The [AGE] year-old resident (Resident # 1) had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 pushed an [AGE] year-old male resident (Resident #4) to the floor in July, 2022, followed by Resident #1 grabbing the wrist of a [AGE] year-old female resident (Resident # 6) causing a bruise in August, 2022, then punched a [AGE] year-old male resident (Resident # 2) in the chest, September, 2022, and intimidated and threatened physical harm through verbal communication to a [AGE] year-old male resident (Resident #3) in September, 2022 causing fear. The immediate jeopardy began on 07/16/22 when Resident #1, who was cognitively intact, pushed Resident #4, who was a cognitively impaired wanderer, to the floor. The immediate jeopardy was removed on 09/24/22 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm) to ensure monitoring systems are put into place are effective. The findings included: A review of a Facility Reported Incident dated 09/10/21 at 9:50 PM indicated Resident #1 hit a resident (Resident #8). The 5-Day Working Report Summary indicated on 09/10/21 Resident #1 was witnessed by a facility NA (unidentified in report) to go up to Resident #8 and began calling her names and placed both his hands on her and began to shake her. 1. Resident #1 was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and independent for all activities of daily living. Resident #1 was identified as being Supervision (requiring no hands-on assistance) with setup help assistance for activities of daily living (ADL) and no behaviors indicated. a. Resident #4 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An annual MDS dated [DATE] indicated Resident #4 was cognitively impaired and required supervision assistance for ambulation and locomotion. Resident #5 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS dated [DATE] indicated Resident #5 was cognitively intact. An incident report dated 7/16/22 at 6:35 AM filed under Resident #1's name indicated Resident #1 allegedly pushed Resident #4 out of his room doorway to the floor in an attempt to remove Resident #4 from his room which was witnessed by Resident #1's former girlfriend, (Resident #5) who was also a resident in the facility, whom summoned assistance of a nurse aide (Nurse Aide #1) whom assisted Resident #4 to his feet and away from Resident #1's room. An additional incident report dated 7/16/22 at 6:35 AM filed under Resident #4's name indicated Resident #5 reported she went to Resident #1's room. Resident #5 indicated when she started to leave, she noticed Resident #4 in the doorway and told him to back up. Resident #5 indicated as she started towards to door to assist him to leave, Resident #1 told Resident #4 to get the F*** out of his room and proceeded to get up from his bed and pushed Resident #4 down to the floor and Resident #5 immediately went to get assistance. The incident further details as Resident #5 reported this incident to Nurse Aide (NA) #1, Resident #4 was visualized on all 4's with his head down to the floor in the hallway outside of Resident #1's room where she picked him up and noticed a small abrasion over his right eyebrow, the nurse provided treatment to the area, and Resident #4 was escorted to the lobby of the unit while the local police department were notified. An investigation report document provided by the facility indicated on 07/16/22 at approximately 5:30 AM, Resident #4 was found on the floor outside the room of Resident #1. It indicated Resident #5 had approached a Nurse Aide (NA #1) to report she had witnessed Resident #1 push Resident #4 out of his room. Resident #4 was assessed for injuries and found to have an abrasion to his right eyebrow and treatment was provided. Resident #4 was taken to the common area and placed on 1:1 for a week due to his high risk for wandering and exit seeking behaviors. The local police department was alerted of the incident and when onsite counseled Resident #1 on his engagement with other residents when upset. They also determined Resident #1 had improved significantly since admission and no longer needed skilled nursing care and issued a 30-day discharge notice to Resident #1 who appealed the decision for discharge. A statement dated 7/16/22 written by the former Staff Scheduler revealed NA #1 stopped her in the hallway at about 6:15 AM to report that Resident #1 had pushed Resident #4 to the floor. She explained that NA#1 told her Resident #5 was present in the room when the incident occurred. Nurse #1 who was present on the hall was informed and then the Administrator was made aware. A statement dated 7/16/22 written by NA #1 revealed she heard Resident #1 yelling when she came around to see what was going on she saw Resident #4 fall from the room of Resident #1 out the door. NA #1 asked Resident #1 if he pushed Resident #4, but he denied it and said he just fell . NA #1 wrote she asked Resident #5 what happened and Resident #5 again verified Resident #1 pushed Resident #4 out of his room. A statement written by Nurse #2 on behalf of Resident #5 indicated on the morning of 7/16/22 at approximately 6:35 AM she went to Resident #1. While in the room, Resident #4 wandered into the room and she asked him to back up. When she was going to attempt to help him out, Resident #1 yelled at Resident #4 to get the F*** out of here and proceeded to get out of bed and pushed Resident #4 to the floor. Then she left to get help. The statement further details the NA saw Resident #4 on the floor and helped him up and took him to the couch to sit down and then the nurse came over to talk to him. A statement written by Nurse #1 dated 7/16/22 indicated she heard a thud on the hallway and turned around and saw Resident #4 on his hands and knees in a crawling position with his head down outside of Resident #1's door. Resident #4 was assessed to have a small blister on his forehead similar to a carpet burn. The note indicated Resident #1 later in the day did admit to pushing Resident #4 because he was in his room. A statement written by the Social Worker (SW) #1 dated 7/18/22 indicated Resident #1 was interviewed by her and the Administrator and denied pushing Resident #4 and claimed he tripped over his shoelace when he wandered into his room around 3:00 AM on 7/16/22. The facility provided documents titled Action Round Sheets dated 7/19/22, 7/20/22, 7/21/22, 7/23/22, and 7/24/22 for 4 residents including Resident #4; however, Resident #1 was not included in these records. Action Round Sheets are a facility developed document to indicate a resident is on either a 1:1 supervision or every 15-minute (q15 min) observation checks where staff are to document an identified location of the designated resident and initial on a q15 min timeline basis. A review of email correspondence between the county Ombudsman and the Facility Administrator dated 07/21/22 through 07/28/22 indicated on 07/21/22, the facility Administrator reached out to the Ombudsman to request an in-person facility visit to review some ongoing concerns of the facility. The Ombudsman responded she would visit the facility on 07/26/22 at 1:30 PM. Additional correspondence continued on 07/28/22 to follow up on resources for available law enforcement support at the facility of which the Ombudsman indicated she would be back in touch with answers when they were available. An interview with Resident #1 on 09/21/22 at 11:15 AM revealed he denied all allegations related to touching Resident #4 on 07/16/22. Resident #1 would not even acknowledge Resident #4 being in his room. Resident #4 was cognitively impaired and therefore could not be interviewed during the survey. Resident #5 was no longer a resident of the facility and her phone number upon discharge was no longer a working number and therefore could not be interviewed during the survey. b. Resident #6 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] obstructive pulmonary disease and chronic pain. A significant change MDS dated [DATE] indicated Resident #6 was cognitively intact and was independent for all activities of daily living. Resident #7 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A MDS dated [DATE] indicated Resident #7 was cognitively intact. An incident report dated 08/18/22 indicated Resident #6 reported that Resident #1 grabbed her wrist and twisted it which resulted in visible bruising. Resident #1 indicated Resident #6 slapped him across the face. A statement written by Resident #1 dated 08/18/22 indicated he and Resident #6 were in the courtyard smoking while the maintenance employee was attempting to clean the area. Resident #1 wrote that Resident #6 would not move so he got the blower and started blowing the area. Resident #1 indicated Resident #6 slapped him so he grabbed her wrist and held her hand up and then let her go. A statement written by the SW #1 on behalf of Resident #6 written on 8/18/22 indicated Resident #1 and Resident #6 had been outdoors in the smoking courtyard before lunch and talking with friends when the maintenance employee was attempting to blow the cigarette butts with the leaf blower. Resident #6 indicated Resident #1 began running his mouth and trying to cut her conversation off when she told him he was being rude so he asked the maintenance employee for the blower to help. Resident #1 was provided the blower and he began blowing the cigarette butts towards Resident #6's direction and she told him to stop that. Resident #6 stated Resident #1 grabbed her left wrist and twisted it and she told him to turn her loose. Resident #6 stated Resident #1 told her he would break her M***** F****** wrist. Resident #6 admitted she tapped Resident #1 on the head trying to get him to stop and Resident #1 again threatened Resident #6 and stated if she ever put her hands on him again he would kill her and he rolled off and she entered the building to report what happened. A written statement by the Maintenance employee dated 08/18/22 indicated he was outside in the area cleaning the area. The Maintenance employee wrote he witnessed Resident #6 slap Resident #1 in the face because he was trying to clean the way so the Maintenance man could clear the area because there was stuff on the ground that needed to be picked up. A review of documents provided by the facility titled, Action Round Sheet with Resident #1's name identified at the top dated 08/18/22, 08/19/22, 08/20/22, 8/21/22, and 8/23/22 indicated on the first sheet was initiated on 08/18/22 at 3:30 PM and Resident #1 was identified to be in various locations throughout the facility until 6:45 AM on 08/19/22. The second page of the document indicated it began at 7:00 AM on 08/19/22 and indicated Resident #1 left the facility for leave of absence (LOA- where the resident can sign themselves out of the facility to spend time in the community unsupervised) at 2:15 PM; however, Resident #1's nurse documentation reflected Resident #1 left the facility in stable condition at 3:19 PM on 08/19/22 and did not indicate when he returned to the facility. Page 2 of the document titled, Action Round Sheet reflected staff continued to document Resident being on LOA until 7:00 PM; however, did not reflect he returned to the facility on that date. Page 3 of the document indicated Resident #1 did not return to the facility until 5:15 PM on 8/20/22 and only indicated he was monitored through 7:00 PM on this date. The facility's document had page 4 missing which should include 8/22/22 and continued with page 5 to reflect q15 minute checks for Resident #1's whereabouts from 7:00 AM until 9:30 AM on 8/23/22. The Action Round Sheets provided did not indicate the length of time Resident #1 was to be placed on 1:1 supervision. A grievance and concern dated 8/18/22 indicated a resolution signed 8/22/22 with the police contacted due to the altercation. Documents provided by the facility dated 08/18/22 indicated alert and oriented residents were interviewed on whether they felt safe and comfortable at the facility of which multiple residents indicated No. The documents were questionnaires and did not include further details to the resident's individual fears nor were they signed by the staff conducting the interview. A statement written by SW #1 on 08/25/22 indicated Resident #7 was interviewed and stated he saw part of the interaction between Resident #1 and Resident #6 on 08/18/22, but refused to discuss which part and stated, What Resident #6 said is correct. An additional interview statement with Resident #7 in the presence of the Administrator on 08/25/22 indicated he only saw Resident #1 and Resident #6 exchange words that began in frustration over blowing of trash in the courtyard. The statement indicated he did not witness Resident #1 grab Resident #6's arm. An interview with Resident #1 on 09/21/22 at 11:15 AM revealed he would not discuss the events related to the incident between him and Resident #6. The only discussion Resident #1 would provide related to the incident was that neither decided to press charges on the other because we were both having a bad day. An interview with Resident #6 and Resident #7 on 09/23/22 at 10:15 AM revealed they both recalled the incident between Resident #1 and Resident #6 on 08/18/22 which occurred in the courtyard of the facility while they were all gathered to smoke. Resident #6 indicated on 08/18/22, the maintenance employee was outside in the courtyard using a leaf blower to blow off the sidewalks while several residents were talking. Resident #6 stated Resident #1 kept attempting to cut her conversation off and she turned to him and told him he was being rude and asked him to quit interrupting her. A few minutes later, Resident #1 asked the maintenance employee to use the leaf blower of which he allowed. When Resident #1 picked up the leaf blower, he began blowing the cigarette butts in the direction of Resident #6 causing dirt, mulch, and cigarette butts to fly up on Resident #6's clean white pants. Resident #6 says she told him again to stop and he then pointed the leaf blower directly at her and it touched her pants. She reached out and went to move the blower off her and Resident #1 grabbed her arm and twisted it. In Resident #6's attempt to get Resident #1 to let go, she then open handedly popped Resident #1 on the side of the head before he let go. Resident #6 and Resident #7 indicated Resident #1 told her he would break her M***** F****** wrist before letting her go. Immediately following the incident, Resident #6 and Resident #7 in agreement indicated Resident #1 stated, If you ever put your F****** hands on me again, I'll kill you. Resident #6 immediately left the courtyard to alert staff and Resident #7 stated Resident #1 went to another area of the courtyard. Resident #7 stated he didn't like to get involved because that stuff happens around here all of the time, do you realize where you are? c. Resident #3 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS dated [DATE] indicated Resident #3 was cognitively intact and required total dependence with ADL. A nurse progress note dated 09/09/22 indicated Resident #1 was overheard by Nurse #3 yelling and cursing. When she arrived at the room, she overheard Resident #1 communicate to Resident #3, If you don't shut the f*** up yelling all the time, I am going to do something to help you stop yelling. The note indicated she told Resident #1 to leave the room and that he was not supposed to be in Resident #3's room. The note further stated Resident #1 wheeled off down the hallway and Nurse #1 reported the incident to the Director of Nursing (DON). A nurse progress note dated 09/19/22 written by Nurse #4 indicated Resident #1 was again observed by staff using threatening profanity towards Resident #3 after he was told multiple times to stay out of other residents' rooms. An unidentified NA assisted Resident #1 out of the room and frequent rounds were made to observe for behaviors through the remainder of the shift. An interview with Resident #1 on 09/21/22 at 11:15 AM revealed he recalled the interaction between himself and Resident #3; however, immediately said, I didn't touch him, I just told him to quit yelling because he was disturbing everyone. He further vocalized, the staff always lie on me. I don't hurt anyone. I am the resident council president and I do all kinds of things for other residents and staff and this is how I am repaid. I watch after all of these residents. An interview with Resident #3 on 09/22/22 at 9:20 AM revealed he recalled Resident #1 making threatening statements and cursing profanity towards him on multiple incidents over the last couple weeks. He indicated Resident #1 had recently come into his room and threatened to hurt him. Resident #3 stated he could not defend himself if Resident #1 did hit him and he was fearful he would come back and hurt him. Resident #3 communicated he was glad Resident #1 didn't have access to a pipe because he [NAME] like Resident #1 was crazy and in his anger would beat him and kill him. Resident #3 stated he has reported this to staff and they have observed Resident #1 in his room before but they don't do anything about it. Resident #3 stated after the incident on 09/19/22, he ended up crying after he was alone because he felt so frightened and fearful. Interview with the Administrator on 09/22/22 at 11:27 AM revealed he was not made aware of the verbal threat by Resident #1 towards Resident #3 that occurred on the night it occurred which was on Friday, 9/9/22, but instead learned of the interaction on Monday 9/12/22 during morning meeting and the team had the PA to evaluate Resident #3 because of his recent yelling episodes. He stated the facility moved Resident #3's roommate at the time and made medication adjustments at the end of August which he thought was correcting the problem but on 9/14/22 the PA had saw Resident #3 again and the changes had not improved the situation and yelling out had increased again. The Administrator stated the facility had attempted to issue Resident #1 a discharge but had been unsuccessful in securing him placement. d. Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] indicated Resident #2 was cognitively intact and required limited to extensive assistance for ADL. Review of the incident report dated 9/17/22 at 10:50 AM indicated Resident #1 punched Resident #2 in the chest which was witnessed by the Human Resources Manager (HR) through her office window which is adjacent to one of the facility's smoking courtyards. A review of the HR Manager's Statement dated 9/17/22 indicated she was sitting in her office and she heard yelling coming from Resident #1. She looked out her window to witness Resident #1 punch Resident #2 in the chest. She got up from her desk and ran outside. She wrote she did not approach Resident #1 but started calling his name to get his attention. An interview with the HR Manager on 09/21/22 at 3:40 PM revealed she was in her office at the time of the interaction between Resident #1 and Resident #2 on 09/17/22. The HR Manager indicated she heard a commotion outside and heard Resident #1 yelling because they were right in front of her window of her office. The HR Manager said she turned to look outside to see what was going on and witnessed Resident #1 punch Resident #2 in the chest. She indicated she immediately got up from her office and approached the smoking courtyard which was adjacent. The HR Manager stated she stood in the doorway of the courtyard hollering Resident #1's name before he acknowledged she was speaking to him. She indicated she did not go outside to physically intervene at that time because Resident #1 was no longer punching Resident #2. The HR Manager said when Resident #1 acknowledged her calling his name was when the current Scheduling Coordinator (Scheduling Coordinator #2) approached the area and went outside to tell Resident #2 to go back to his room and the HR Manager said she left the area and went to report the incident to the Activity Director and had no further involvement in the interaction. An interview with the Activity Director (AD) on 09/21/22 at 3:55 PM revealed she was on duty on 09/17/22 when the HR Manager reported to her that she witnessed Resident #1 punch Resident #2 in the chest. The AD indicated she did not intervene in the altercation between the residents, but only notified the Manager on Duty and the Administrator of the occurrence. An interview with Scheduling Coordinator #2 on 09/21/22 at 4:00 PM revealed she was on duty on 09/17/22 and was standing at the front entrance to the facility when she saw the HR Manager leave her office and heard her shouting at Resident #1 that he could not put his hands on another resident. The Scheduling Coordinator #2 stated she immediately went towards the smoking courtyard area and passed the HR Manager in the doorway and went outside and told Resident #2 to leave the courtyard and go back to his room. A progress note dated 9/17/22 at 12:13 PM written by the Activity Director indicated staff reported to her that Resident #1 punched another resident in the chest in the courtyard. Resident #2 was removed from the area at that time. It further detailed no injuries were observed at the time. Resident #1 was placed on 1:1 at that time and asked to give up his smoking materials but refused. He was told he was not to smoke in the same courtyard, but to go out front and to the left to smoke with supervision. While the police were in the building investigating, Resident #1 yelled at the police and zoomed away from them in his wheelchair while he was being interviewed. The Clinical Manager on Duty and Administrator were notified. An interview with Resident #1 on 09/21/22 at 11:15 AM revealed he denied punching/hitting Resident #2 and said the staff were lying on him. He did admit he was out in the smoking courtyard on 9/17/22 at about 10-11 AM when he observed Resident #2 outside. He indicated Resident #2 had removed the lid from the smoking ashtray and was attempting to retrieve cigarette butts when he intervened and took the ashtray lid from Resident #2. Resident #1 stated the HR Manager approached the area after he blessed Resident #2 out and told him he could not be digging in the ashtray and accused him of hitting Resident #2. He stated the facility put him on 1:1 observation that day, but he did not want to be babysat so he called a friend and signed himself out of the facility. He stated he was not put back on 1:1 until Monday afternoon following being called to the Administrator's office about the incident that occurred on 9/17/22. An interview with Resident #2 on 09/22/22 at 4:30 PM revealed he was out in the courtyard on 9/17/22 attempting to retrieve cigarette butts from the ashtray because he had no money currently to purchase more. Resident #2 stated Resident #1 approached him punched him in the chest and back/side (flank area) then grabbed the lid of the ashtray from him and it fell to the ground. Shortly after this a staff member approached the courtyard and told him to go back to his room. Resident #2 said he didn't get hurt that day, but he was fearful of Resident #1 repeating this behavior in the future. An interview with the Administrator on 09/22/22 at 11:27 AM revealed the investigation regarding Resident #1 and Resident #2 was ongoing and did not provide any further details regarding its current status or the root cause. He simply stated the facility was in the process of planning to get Resident #1 discharged from the facility. A telephone interview with the PA on 09/22/22 at 1:30 PM revealed she was familiar with Resident #1 and felt he was not appropriate for skilled level of care and posed a threat to other residents in the facility as a result of his aggressive behaviors. She stated she was made aware of the incident between Resident #1 and Resident #2 when she arrived at the building on Tuesday 09/20/22 which was 3 days following the event. She stated she assessed Resident #2 at that the time and did not find obvious physical injuries and stated she did not visit Resident #1 on that date; however, she was aware he was known to be manipulative and have the ability to hide his outburst from her and the Medical Director during their visits by minimizing a lot of the details that transpired. An interview with the MD on 09/22/22 at 12:57 PM revealed he had not yet been made aware of the interaction between Resident #1 and Resident #2 which occurred on 09/17/22; however, did not feel Resident #1 was appropriate for skilled level of care and felt he needed to be discharged to a different type of setting due to his high physical functioning abilities. The MD stated Resident #1 has known outburst behaviors and a complete lack of concern for others, he wants it his way or no way. The MD also indicated due to his physical independence and his disruptive behavior with physical and verbal aggression towards others he posed a risk to all other residents who remain in the facility at present. The Administrator, Director of Nursing, and 2 members of the corporate staff were notified of immediate jeopardy on 09/22/22 at 6:15 PM. The facility provided the following immediate jeopardy plan for removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: The facility failed to protect residents' rights to be free from verbal and physical abuse. A cognitively intact resident has abused 4 residents. Residents are fearful and have endured bruising and verbal and physical abuse. All residents are at risk for abuse. On 9/23/2022 Dietary Manager/Unit Manager completed interviews with all residents with a Brief Interview for Mental Status (BIMS) score of 9 or higher on abuse to ensure no further incidents of abuse. Director of Nursing and floor nurses completed skin audits for signs of abuse as of 9/23/2022 for all residents with a BIMS score of 8 or lower. On 7/16/2022 resident #1 allegedly pushed resident #4 causing resident #4 to fall to the floor. Nurse #1 immediately intervened with the confrontation. Nurse #1 separated Resident #1 and Resident #4 by having Resident #1 stay in his room and Resident #4 was placed on 1 on 1 monitoring by nursing assistant #1. 1 on 1 monitoring for Resident # 4 was for 72 hours. Nurse #1 provided assistance to Resident #4 and first aid. Police were contacted by Administrator on 7/16/2022 immediately following notification. Police officer interviewed Resident #1 and informed him that he cannot push or touch other residents. Facility Administrator determined that Resident #4 was wandering into Resident #1's room uninvited. On 7/18/2022 Administrator, Director of Nursing, Social Worker, and Physician determined that Resident #1 no longer required Skilled Nursing Level care. Administrator informed Social Worker to start discharge process for Resident #1 for placement in Assisted Living. On 7/18/2022 Social Worker started sending Resident #1's information to assisted living facilities for placement. On 7/18/2022 Administrator had a conversation with Resident#1 on the rules and policies about touching and or engaging in confrontation with other residents. Resident #1 informed Administrator that he understood. Administrator continued 1 on 1 supervision with Resident #1 for one week starting 7/16/22 through 7/24/22 and determined that resident #1 was not a risk to other residents related to Resident #4 entering his room and refusing to leave. As of 7/21/2022 all staff including agency staff were re-educated on facility abuse policy related to preventing and reporting abuse. On 8/18/2022 it was reported to Social Worker that Resident #1 grabbed Resident #6's wrist lifting her off the ground in the smoking area. Resident #1 and Resident #6 were immediately separated by facility staff. Facility Administrator was notified on 8/18/2022 by facility staff of the incident. Resident #1 was immediately placed on 1 on 1 supervision on 8/18/2022 for 96 hours to prevent any further incidents. Administrator contacted the police department of the alleged incident on 8/18/2022 immediately following notification of incident. Administrator started the investigation of the incident on 8/18/2022. Beginning on 8/18/2022 Administrator, Director of Nursing, Social Worker and Activities Director began interviewing all residents with a BIMS score of 10 or higher as well as witness Resident #7 and or staff who were in the smoking area at time of incident on 8/18/22. During the investigation and witness interviews it was determined by the Administrator that Resident #6 had slapped Resident #1 prior to Resident #1 grabbing Resident #6 wrist. Administrator determined that Resident #1 was not a danger to other residents in the facility. On 8/18/2022 Police Officer counseled Resident #1 on social behaviors. At time of incident on 8/18/2022 facility had already begun discharge process and were looking for alternate placement in an Assisted Living facility for Resident #1. Administrator and Director of Nursing re-educated all staff to include agency staff on facility abuse policy regarding reporting and preventing abuse as of 8/22/2022. On 9/9/22 Resident #1 was heard yelling with profanity at Resident #3 in Resident #3's room to stop yelling or he would make him shut up by nurse #1. Nurse # 1 immediately removed Resident #1 from Resident #3's room. Nurse continued to monitor Resident #1 throughout the night to ensure he did not return to Resident #3's room. Nurse #1 documented that Resident #3 was noted to be without distress following the incident. On 9/17/2022 Resident #1 was seen in the smoking area by Human Resource Manager (HR) punching Resident #2 in the chest. Human Resource Director immediately went outside and deescalated the residents and had the Activity Director separate Resident #1 and Resident #2. Activity Director notified the Administrator on 9/17/2022 following the incident. Administrator immediately informed the Regional Director of Operations of the incident on 9/17/2022. Regional Director of Operations instructed the Administrator to start 1 on 1 supervision of Resident #1 until Administrator can get Resident #1 placed in Assisted Living. Administrator placed Resident #1 on 1 on 1 supervision beginning 9/17/2022 with no end date. Administrator began investigation of alleged incident on 9/17/2022. Facility has continued 1 on 1 supervision while looking for alternative placement. On 9/19/2022 Resident #1 was heard yelling threatening profanity at Resident #3. Nurse #1 removed Resident #1 from Resident #3's room immediately and continued his 1 on 1 supervision. Resident #1 had returned from outside visit and facility wasn't aware he had returned at that time and 1 on 1 was not in place. Facility receptionist has been in-serviced on resident requiring 1 on 1 supervision by the Regional Clinical Director on 9/23/2022 to ensure no resident with 1 on 1 in place return into the facility until 1 on 1 employee accompanies resident into f [TRUNCATED]

Based on resident and staff interviews, record review and policy review, the facility failed to thoroughly investigate abuse and protect the residents from further abuse for three (3) of 4 residents reviewed for abuse (Resident #2, Resident #4, and Resident #6). Specifically, when Resident #1 began exhibiting verbally and physically aggressive behaviors directed towards others in July 2022, the facility failed to implement effective measures to prevent further abuse due to all interventions placed during investigations by the facility were temporary and their discontinuation left other residents at risk for potential of abuse. The facility also failed to notify Adult Protective Services (APS) for 4 of 4 allegations of abuse (Resident #2, Resident #3, Resident #4, and Resident #6) and failed to notify and involve law enforcement for 2 of 2 allegations of abuse (Resident #3 and Resident #4). The immediate jeopardy began on 07/16/22 when Resident #1 pushed Resident #4 to the floor and the facility did not thoroughly investigate and put effective interventions in place to protect the remaining residents in the facility. The immediate jeopardy was removed on 09/24/22 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems are put into place are effective. Findings included: 1. Resident #1 was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and independent for all activities of daily living. An incident report dated 7/16/22 at 6:35 AM filed under Resident #1's name indicated Resident #1 allegedly pushed Resident #4 out of his room doorway to the floor in an attempt to remove Resident #4 from his room which was witnessed by Resident #1's former girlfriend, (Resident #5) who was also a resident in the facility, which summoned assistance of a nurse aide (Nurse Aide #1) which assisted Resident #4 to his feet and away from Resident #1's room. An additional incident report dated 7/16/22 at 6:35 AM filed under Resident #4's name indicated Resident #5 reported she went to Resident #1's room. Resident #5 indicated when she started to leave, she noticed Resident #4 in the doorway and told him to back up. Resident #5 indicated as she started towards to door to assist him to leave, Resident #1 told Resident #4 to get the F*** out of his room and proceeded to get up from his bed and pushed Resident #4 down to the floor and Resident #5 immediately went to get assistance. The incident further details as Resident #5 reported this incident to NA #1, Resident #4 was visualized on all 4's with his head down to the floor in the hallway outside of Resident #1's room where she picked him up and noticed a small abrasion over his right eyebrow, the nurse provided treatment to the area, and Resident #4 was escorted to the lobby of the unit while the local police department were notified. An investigation report document provided by the facility indicated on 07/16/22 at approximately 5:30 AM, Resident #4 was found on the floor outside the room of Resident #1. It indicated Resident #5 had approached a Nurse Aide (NA #1) to report she had witnessed Resident #1 push Resident #4 out of his room. Resident #4 was assessed for injuries and found to have an abrasion to his right eyebrow and treatment was provided. Resident #4 was taken to the common area and placed on 1:1 for a week due to his high risk for wandering and exit seeking behaviors. The local police department was alerted of the incident and when onsite counselled Resident #1 on his engagement with other residents when upset. On 7/18/22, the Social Worker (SW #1) made attempts to contact other local nursing facilities to attempt to locate a secured unit for Resident #4. They also determined Resident #1 had improved significantly since admission and no longer needed skilled nursing care and issued a 30-day discharge notice to Resident #1 who appealed the decision for discharge. The facility provided documents titled Action Round Sheets dated 7/19/22, 7/20/22, 7/21/22, 7/23/22, and 7/24/22 for 4 residents including Resident #4; however, Resident #1 was not included in these records of residents to be watched at that time although his care plan dated 7/18/22 indicated an intervention of 1:1-gently encourage resident to notify staff of any incidents and provide staff time to provide resolution. Action Round Sheets are a facility developed document to indicate a resident is on either a 1:1 supervision or every 15-minute (q15 min) observation checks where staff are to document an identified location of the designated resident and initial on a q15 min timeline basis. Again, Resident #1 was not included in the internal facility document titled Action Round Sheets. There was no evidence that the resident-to-resident altercation between Resident #1 and Resident #4 was thoroughly investigated; reported to the local law enforcement or APS. The intervention of 1:1 supervision put in place for Resident #4 did not ensure Resident #1 did not pose further danger to all other residents in the facility at the time of the incident. An incident report dated 08/18/22 indicated Resident #6 reported that Resident #1 grabbed her wrist and twisted it which resulted in visible bruising. Resident #1 indicated Resident #6 slapped him across the face. A review of documents provided by the facility titled, Action Round Sheet with Resident #1's name identified at the top dated 08/18/22, 08/19/22, 08/20/22, 8/21/22, and 8/23/22 indicated on the first sheet was initiated on 08/18/22 at 3:30 PM and Resident #1 was identified to be in various locations throughout the facility until 6:45 AM on 08/19/22. The second page of the document indicated it began at 7:00 AM on 08/19/22 and indicated Resident #1 left the facility for leave of absence (LOA- where the resident can sign themselves out of the facility to spend time in the community unsupervised) at 2:15 PM; however, Resident #1's nurse documentation reflected Resident #1 left the facility in stable condition at 3:19 PM on 08/19/22 and did not indicate when he returned to the facility. Page 2 of the document titled, Action Round Sheet reflected staff continued to document Resident being on LOA until 7:00 PM; however, did not reflect he returned to the facility on that date. Page 3 of the document indicated Resident #1 did not return to the facility until 5:15 PM on 8/20/22 and only indicated he was monitored through 7:00 PM on this date. The facility's document had page 4 missing which should include 8/22/22 and continued with page 5 to reflect q15 minute checks for Resident #1's whereabouts from 7:00 AM until 9:30 AM on 8/23/22. The Action Round Sheets provided did not indicate the length of time Resident #1 was to be placed on 1:1 supervision. Review of Resident #1's medical record revealed no other interventions implemented to mitigate the risk of further abuse to other residents. The care plan only included a duplication of the 7/18/22 intervention with an updated date of 8/19/22 which indicated 1:1-gently encourage resident to notify staff of any incidents and provide staff time to provide resolution. Documents provided by the facility dated 08/18/22 indicated alert and oriented residents were interviewed on whether they felt safe and comfortable at the facility of which multiple residents indicated No. The facility was unable to provide any documentation of interventions that were provided to the alert and oriented resident that verbalized they were fearful of living at the facility. There was no evidence that the resident-to-resident altercation between Resident #1 and Resident #6 was thoroughly investigated; reported to APS. The intervenetions placed for Resident #1 were not monitored to effectively ensure they did prevented further danger to all residents in the facility at the time of the incident. Resident #1 was placed on a temporary 1:1 supervision; however, he signed himself out of the facility on a leave of absence and did not alert staff upon return to resume 1:1 supervision or re-evaluate him for continuation of 1:1 monitoring; therefore, when he returned to the facility he was not monitored to ensure others safety. A nurse progress note dated 09/09/22 indicated Resident #1 was overheard by Nurse #1 yelling and cursing. When she arrived at the room, she overheard Resident #1 communicate to Resident #3, If you don't shut the f*** up yelling all the time, I am going to do something to help you stop yelling. The note indicated she told Resident #1 to leave the room and that he was not supposed to be in Resident #3's room. The note further stated Resident #1 wheeled off down the hallway and Nurse #1 reported the incident to the Director of Nursing (DON). A nurse progress note dated 09/19/22 indicated Resident #1 was again observed by staff using threatening profanity towards Resident #3 after he was told multiple times to stay out of other resident's rooms. An unidentified NA assisted Resident #1 out of the room and frequent rounds were made to observe for behaviors through the remainder of the shift. An interview with Resident #3 on 09/22/22 at 9:20 AM revealed he recalled Resident #1 making threatening statements and cursing profanity towards him on multiple incidents over the last couple weeks. He indicated Resident #1 had recently come into his room and threatened to hurt him. Resident #3 stated he could not defend himself if Resident #1 did hit him and he was fearful he would come back and hurt him. Resident #3 communicated he was glad Resident #1 didn't have access to a pipe because he feels like Resident #1 is crazy and in his anger would beat him and kill him. Resident #3 stated he has reported this to staff and they have observed Resident #1 in his room before but they don't do anything about it. Resident #3 stated after the incident on 09/19/22, he ended up crying after he was alone because he felt so frightened and fearful. Interview with the Administrator on 09/22/22 at 11:27 AM revealed he was not made aware of the verbal threat by Resident #1 towards Resident #3 that occurred on the night it occurred which was on Friday, 9/9/22, but instead learned of the interaction on Monday 9/12/22 during morning meeting and the team had the Nurse Practitioner to evaluate Resident #3 because of his recent yelling episodes. He stated the facility moved Resident #3's roommate at the time and made medication adjustments at the end of August which he thought was correcting the problem but on 9/14/22 the NP had saw Resident #3 again and the changes had not improved the situation and yelling out had increased again. The Administrator stated the facility had attempted to issue Resident #1 a discharge but had been unsuccessful in securing him placement. There was no evidence that the resident-to-resident altercation between Resident #1 and Resident #3 was investigated by the facility; reported to the State Agency, Local Law Enforcement, or APS; and there were no interventions were placed for Resident #1 to ensure he did not pose further danger to Resident #3 or any other residents in the facility at the time of the incident. Resident #1 was observed not to be on 1:1 supervision on 09/19/22 when he returned to Resident #3's room and verbally abused Resident #3 for a second time causing Resident #3 to remain fearful. Review of the incident report dated 9/17/22 at 10:50 AM indicated Resident #1 punched Resident #2 in the chest which was witnessed by the Human Resources Manager (HR) through her office window which is adjacent to one of the facility's smoking courtyards. Attempts were made to contact the former Social Worker (SW #1) were unsuccessful during the investigation. A progress note written by the Social Worker (SW #2) on 09/20/22 at 5:17 PM indicated she, the HR Manager and the Activity Director went to the magistrate's office to see what could be done regarding Resident #1's aggressive behaviors to include a possible arrest or warrant; however, the magistrate explained the process to facility staff in which the police officers would have to take initiative which would be handled outside of the magistrate's office. An investigation report by the facility which indicated on 09/20/22 at 12:30 PM, the police officers and the magistrate had a telephone conversation with the facility and the magistrate/police officers advised the facility they could not arrest Resident #1 because they did not see the injuries and magistrate had consulted with the officer's attorney to see how to help the situation legally. The officers advised the facility to discharged Resident #1 immediately for the safety of the other residents. The resident-to-resident altercation between Resident #1 and Resident #2 was not reported to APS at the time of the initial report. Resident #1 was placed on 1:1 supervision on the date of the incident (09/17/22); however, was observed not to be on 1:1 supervision on 09/19/22 when he was observed to be making verbal threats towards Resident #3 and the resident's had to be separated by the nurse. The Administrator, Director of Nursing, Regional Nurse Consultant and Regional Operations Director were notified of immediate jeopardy on 09/22/22 at 6:15 PM. The facility provided the following immediate jeopardy plan for removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the non- compliance: After a cognitively intact resident abused a resident in July, the facility failed to implement effective measures to protect all residents. After a cognitively intact resident abused a resident in August, the facility failed to implement effective measures to protect all residents. After a cognitively intact resident abused a resident in September, the facility failed to implement effective measures to protect all residents and there was an additional abuse of another resident in September. The facility failed to protect residents' rights to be free from verbal and physical abuse. A cognitively intact resident has abused 4 residents. Residents are fearful and have endured bruising and verbal and physical abuse. All residents are at risk for abuse. On 9/23/2022 Dietary Manager/Unit Manager completed interviews with all residents with a Brief Interview for Mental Status (BIMS) score of 9 or higher on abuse to ensure no further incidents of abuse. Director of Nursing and floor nurses completed skin audits for signs of abuse as of 9/23/2022 for all residents with a BIMS score of 8 or lower. On 7/16/2022 Resident #1 allegedly pushed Resident #4 causing Resident #4 to fall to the floor. Nurse #1 immediately intervened with the confrontation. Nurse #1 separated Resident #1 and Resident #4 by having Resident #1 taken to common area of the facility and placed on 1:1 by nursing assistant #1. Nurse #1 provided assessment of Resident #1 and first aid. Police were contacted by Administrator on 7/16/2022 immediately following notification. Police Officer interviewed Resident #1 and informed him that he cannot push or touch other residents. Facility Administrator determined that resident #4 was wandering into resident #1's room uninvited. On 7/18/2022 Administrator, Director of Nursing, Social Worker, and Physician determined that Resident #1 no longer required Skilled Nursing Level care. Administrator informed Social Worker to start discharge process for Resident #1 for placement in Assisted Living. On 7/18/2022 Social Worker started sending Resident #1's information to assisted living facilities for placement. On 7/18/2022 Administrator had a conversation with Resident#1 on the rules and policies about touching and or engaging in confrontation with other residents. Resident #1 informed administrator that he understood. Administrator continued 1 on 1 supervision with Resident #1 for one week starting 7/16/22 through 7/24/22 and determined that Resident #1 was not a risk to other residents related to Resident #4 entering his room and refusing to leave. As of 7/21/2022 all staff including agency staff were re-educated on facility abuse policy related preventing and reporting abuse. On 8/18/2022 it was reported to Social Worker that Resident #1 grabbed Resident #6's wrist lifting her off the ground in the smoking area. Resident #1 and Resident #6 were immediately separated by facility staff. Facility Administrator was notified on 8/18/2022 by facility staff of the incident. Resident #1 was immediately placed on 1 on 1 supervision on 8/18/2022 for 96 hours to prevent any further incidents. Administrator contacted the police department of the alleged incident on 8/18/2022 immediately following notification of incident. Administrator started the investigation of the incident on 8/18/2022. Beginning on 8/18/2022 Administrator, Director of Nursing, Social Worker and Activities Director begin interviewing all residents with a BIM score of 10 or higher as well as witness Resident #7 and or staff who were in the smoking area at time of incident on 8/18/22. During the investigation and witness interviews it was determined by the Administrator that Resident #6 had slapped Resident #1 prior to Resident #1 grabbing Resident #6 wrist. Administrator determined that Resident #1 was not a danger to other residents in the facility. On 8/18/2022 Police Officer counselled Resident #1 on social behaviors. At time of incident on 8/18/2022 facility had already begun discharge process and were looking for alternate placement in an Assisted Living facility for Resident #1. Administrator and Director of Nursing re-educated all staff to include agency staff on facility abuse policy regarding reporting and preventing abuse as of 8/22/2022. On 9/9/22 Resident #1 was heard yelling at Resident #3 in Resident #3's room to stop yelling or he would make him shut up by Nurse #1. Nurse #1 immediately removed Resident #1 from Resident # 3's room. Nurse continued to monitor Resident #1 throughout the night to ensure he did not return to Resident #3's room. Nurse #1 found no signs of injury to Resident # 3 following the incident. On 9/17/2022 Resident #1 was seen in the smoking area by Human Resource Director (HR) punching Resident # 2 in the chest. Human Resource Director immediately separated Resident #1 and Resident #2. HR Director notified Administrator on 9/17/2022 following the incident. Administrator immediately informed the Regional Director of Operations of the incident on 9/17/2022. Regional Director of Operations instructed Administrator to start 1 on 1 supervision of Resident #1 until Administrator can get Resident #1 placed in Assisted Living. Administrator placed Resident #1 on 1 on 1 supervision beginning 9/17/2022 with no end date. Administrator began investigation of alleged incident on 9/17/2022. Facility has continued 1 on 1 supervision while looking for alternative placement. On 9/19/2022 Resident #1 was heard yelling threatening profanity at Resident #3. Nurse #1 removed Resident #1 from Resident #3's room immediately and continued his 1 on 1 supervision. Resident #1 had returned from outside visit and facility wasn't aware he had returned at that time and 1 on 1 was not in place. Facility receptionist has been in-serviced on resident requiring 1 on 1 supervision by the Regional Clinical Director on 9/23/2022 to ensure no resident with 1 on 1 return into the facility until 1 on 1 employee accompanies resident into facility. All staff in-serviced by Director of nursing on 1 on 1 to include residents return to facility after hours for 1 on 1 in place upon resident return to facility. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. As of 9/23/2022 Regional Director of Operations has reviewed all abuse allegations for Saturn Health & Rehabilitation for period 1/01/2022 - 9/23/2022 to ensure all efforts were taken to complete the investigation, prevent and protect all residents from abuse. Resident #1 has been placed on supervised 1 on 1 monitoring 24 hours per day as of 9/17/2022. As of 9/23/2022 facility has secured alternate placement for resident #1. Activities Director contacted shelter regarding Resident #1. On 9/23/2022 men's shelter agreed to take Resident #1 and he will discharge on 9/23/2022. Director of Nursing informed Resident #1 of the discharge plans on 9/23/2022 and Resident #1 agreed to planned discharge. On 9/22/2022 Regional Clinical Director re-educated the Administrator and Director of Nursing on Abuse reporting, prevention, investigation, and interventions to state agency as well as Regional Director of Operations and Regional Director of Clinical. Education included the facility policy for screening employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal backgrounds check. The facility will not knowingly employ of otherwise engage any individual convicted of resident abuse, neglect, exploitation, misappropriation of resident property, or mistreatment by a court of law or reported abuse as noted by licensure boards or registries. Resident rights and abuse prevention training for all employees is conducted during orientation, and at lease annually, and includes review of: abuse policies and code of conduct, definitions of abuse, resident's rights, abuse, neglect and exploitation policy and criteria for assessing risk factors, management of aggressive behavior, care of cognitively impaired, conflict resolution, stress management and signs of burnout. At the time of admission, each resident and responsible party is informed of the resident's rights and the facility's zero tolerance for any form of abuse. A zero-tolerance policy of abuse, neglect, mistreatment, and misappropriation, along with reporting directions, is posted in the facility or given to the resident upon admission and each employee at orientation. Staff is instructed to report any sign of stress from family or other individuals involved with the resident that may lead to abuse, neglect or misappropriation of resident property and to intervene as appropriate. The facility protects residents and/or families from harm or retaliation during an abuse or neglect investigation. Any person or persons accused or suspected of involvement in resident abuse, neglect or misappropriation of resident property is immediately suspended for the course of the investigation pending the outcome of the investigation. Patient protection actions include immediately removing the patient from contact with alleged abuser during the investigation. If the alleged abuser is not an employee, measures are taken to provide a safe, secure environment for the patient. Action may include: patient room change, patient daily schedule change, visitor restrictions, reporting to other agencies or law enforcement. Human Resources will ensure all new hire orientation on Abuse reporting, prevention, investigation, and interventions to state agency. On 09/23/2022 Human Resource Manager was educated to this responsibility by the Administrator. As of 9/23/2022 all reportable events will be reported to the Regional Director of Operations and/or Regional Director of Clinical immediately following event by the Administrator. Regional Director of Clinical/Regional Director of Operations will review all reportable allegations prior to being submitted from 9/23/2022 ongoing to ensure protective measures are put into place. Date Immediate Jeopardy removed: 9/24/2022 On 9/29/22 the facility's credible allegation of Immediate Jeopardy removal date of 9/24/22 was validated. The validation was evidenced by staff interviews, resident interviews, record reviews, and review of in-service attendance sheets. In-service attendance sheets revealed the Administrator and Director of Nursing had been in-serviced on Abuse prevention, intervention, reporting, and investigation. Record review revealed all reportable events from 1/1/2022 to present (9/29/2022) have been reviewed by the Regional Director of Operations. Interviews with staff revealed a process of screening staff and volunteers prior to resident interaction for reports of convicted resident abuse, neglect, exploitation, misappropriation of resident property or mistreatment. Interviews conducted with staff from all shifts and all disciplines revealed staff aware of the facility's zero tolerance for abuse policy, signs of resident stress to monitor/report, and the immediate removal of any resident who has the potential or was harmed during an incident. Interviews conducted with residents indicated their knowledge of the facility's zero tolerance for abuse policy.

Based on record review, observations, and interviews with the Medical Doctor and staff the facility failed to provide care for an incontinent resident dependent on staff for toilet use and personal hygiene resulting in 2 new areas of moisture associated skin damage being identified for 1 of 3 residents reviewed for activities of daily living (Resident #10). The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #10 as having moderately impaired cognition and always being incontinent of bladder and bowel and totally dependent on staff for transfers, toilet use, and personal hygiene. Review of the care plan last revised on 05/13/22 revealed Resident #10 was at risk for skin breakdown. The goal was for the skin to remain intact through the next review. Interventions included provide prompt incontinence care to keep the skin clean and dry as possible. An observation on 09/27/22 at 3:23 PM revealed Resident #10 sitting in a wheelchair in his room. There was a strong odor resembling urine when entering the room. Resident #10 was wearing a pair of gray shorts that were darker in color at the groin area as if wet. During an interview on 09/21/22 at 3:45 PM NA #2 revealed she just arrived and had checked on residents to ensure they were safe and accounted for. NA #2 did not reveal she had checked Resident #10, and he needed incontinence care. A continuous observation was started on 09/21/22 from 3:23 PM through 5:15 PM. Resident #10 remained in his room sitting in a wheelchair. At 4:11 PM NA #2 entered the room to provide ice and again at 4:16 PM and asked if everything was okay. The roommate of Resident #10 responded yes, and NA #2 left the room. At 5:05 PM NA #2 left the hall. At 5:09 PM this writer showed Med Aide #1 incontinence care was needed for Resident #10. At 5:15 PM NA #2 returned to the hall and began to provide incontinence care for Resident #10. Resident #10's gray shorts were saturated at the front groin and buttocks and the wheelchair cushion had a large wet stain with a strong odor resembling urine. An observation of incontinence care on 09/27/22 at 5:15 PM revealed Resident #10 had an area of red skin involving the left buttocks. During an interview on 09/21/22 at 5:25 PM NA #2 revealed Resident #10 did not make his needs known related to incontinence care and she would have to physically check if the resident had an episode of incontinence. NA #2 revealed she had not checked Resident #10 for incontinence until asked and stated she had assisted two other residents to bed and hadn't gotten to Resident #10. NA #2 indicated she didn't receive report from the previous shift NA assigned to Resident #10. During an interview on 09/21/22 at 6:15 PM the Regional Nurse Consultant was informed of the red area of skin on Resident #10's left inner thigh. The Regional Nurse Consultant stated she would have the Wound Care Nurse check Resident #10 for any skin issues. The Regional Nurse Consultant also observed the wet wheelchair cushion and stated she would ensure it would be cleaned. An interview was conducted on 09/21/22 at 6:32 PM with the Wound Care Nurse. The Wound Care Nurse revealed she identified two new areas on Resident #10's skin and would notify the Medical Doctor (MD) for orders. During a second interview on 09/22/22 at 9:35 AM the Wound Care Nurse revealed new orders were received for skin tears due to moisture associated skin damage to the inner right groin and left buttocks. An interview was conducted on 09/22/22 at 11:03 PM with the MD. The MD revealed being immobile and sitting in a soiled brief would contribute to moisture associated skin damage. An interview was conducted on 09/22/22 at 12:34 PM with NA #3 who worked first shift on 09/21/22 and was assigned to provide care for Resident #10. NA #3 revealed when she first arrived, Resident #10 was already dressed and sitting in the wheelchair, and she didn't physically check him for incontinence. She did physically check Resident #10 before lunch and provided care for an episode of urinary incontinence. NA #3 revealed after that she didn't check Resident #10 for incontinence and stated around 2:00 PM a family member told her they had provided incontinence care and handed her bag with a soiled brief and asked her to discard it. An interview was conducted with the Director of Nursing (DON) on 09/23/22 at 11:44 AM. The DON revealed she would expect nursing staff to provide incontinence care for a dependent resident when visibly wet.

Based on observations, record review and interviews with staff and the Nurse Practitioner, the facility failed to have systems in place to alert staff that a severely cognitively impaired resident had exited the facility for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 who had a diagnosis of dementia exited the facility without staff's knowledge at an undetermined time on 4/25/22 and was found lying on the ground outside at the back of the facility at 6:44 AM by a staff member coming into work. He was assessed and observed with abrasions to both elbows. Immediate Jeopardy began on 4/25/22 when Resident #1 exited the facility without staff knowledge. Immediate Jeopardy was removed on 5/1/22 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education, complete elopement drills and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Resident #1 was admitted to the facility on [DATE] with his most recent re-admission on 1/6/22 with diagnoses that included [CONDITION(S)], chronic obstructive pulmonary disease, congestive heart failure, diabetes, presbyopia (farsightedness), [CONDITION(S)], [CONDITION(S)], and dementia. A document entitled, Order on Application for Appointment of Guardian, dated 6/24/20 in Resident #1's medical record indicated the Court concluded that it was not in the best interest of the respondent (Resident #1) that he retain certain rights and privileges set forth. It was ordered that the person named (Resident #1's responsible party) was appointed as guardian of the respondent to serve in the capacity designated. Resident #1's care plan dated 12/17/21 indicated he was at risk for falls and injury related to weakness, impaired mobility, impaired vision, and poor endurance. His care plan also indicated he had cognitive impairment related to a diagnosis of dementia and he was at risk for having difficulty navigating within the environment and falls related to diagnoses of presbyopia, [CONDITION(S)] of both eyes (early dry stage) and nuclear [CONDITION(S)] to both eyes. Resident #1 did not have a care plan for wandering behaviors or risk for elopement. The Elopement/Wandering Risk Review for Resident #1 dated 1/27/22 indicated Resident #1 was not at risk for elopement/wandering at the time of this assessment. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and had impaired vision and used corrective lenses. Resident #1 was independent with bed mobility but required supervision with transfer, walking and locomotion. His balance during transitions was not steady but he was able to stabilize without staff assistance. Resident #1 did not exhibit wandering behaviors during the assessment period. A document entitled, Resident Incident Report, dated 4/25/22 at 6:46 AM in Resident #1's medical record and completed by Nurse #1 indicated Resident #1 was found outside at the back of the building on the ground by housekeeping. Resident #1 was assessed and assisted to wheelchair and brought in the building for a full assessment and vital signs. Abrasion to both elbows, wounds cleaned with no further care required. A progress note dated 4/25/22 at 7:41 AM written by Nurse #1 indicated assistance was requested by the Administrator with an incident outside at the back of the building. Resident #1 was found outside by the loading dock on the ground on his left side. Resident #1 was questioned as to how he ended up out there, with no clear answer. Resident #1 pointed to the door by the cooler, then he pointed to the back door by the time clock. Housekeeping brought Resident #1's wheelchair out. Resident #1 was assisted to his chair and brought to his room for a full body assessment. Range of motion was performed, resident stated there was some discomfort when raising his left arm. Small abrasions were found on both elbows, area was cleaned and dried, no further care needed. Vital signs were taken, blood pressure elevated at 138/91, pulse 94, temperature 97.2 degrees, oxygen saturation 97%. Resident #1 did not state any further problems at this time. An interview with both Housekeeper #1 and Housekeeper #2 on 4/28/22 at 10:28 AM revealed Housekeeper #1 noticed a man lying on the ground by the loading dock at the back of the facility around 6:44 AM on 4/25/22 when he arrived at the facility for work that day. Housekeeper #1 stated he wasn't sure if the man was a resident or a homeless person, so he went inside the facility and immediately informed Housekeeper #2 to identify the man outside. Housekeeper #2 recognized Resident #1's hat when he went outside so he instructed Housekeeper #1 to get some help. Housekeeper #1 came back with the Administrator who then instructed him to get a nurse. The Administrator asked Resident #1 how he got out of the building, and he pointed towards the doors behind the wall cooler on the loading dock. They asked him how long he had been outside, and Resident #1 stated to them that he might have been outside for about an hour. Housekeeper #1 stated he notified Nurse #1 about Resident #1 lying on the ground at the back of the facility. Housekeeper #1 also obtained Resident #1's wheelchair which was still inside his room. Both Housekeeper #1 and Housekeeper #2 assisted the Administrator and Nurse #1 in getting Resident #1 into his wheelchair and back into the building. Housekeeper #2 stated Resident #1 couldn't have gone out through the doors behind the wall cooler because these doors led to the laundry room which were locked from the inside. They both remembered Resident #1 was wearing jeans, a black and white hat, red tennis shoes, a shirt, and a hoodie. Housekeeper #2 stated Resident #1 was not wearing his glasses. Housekeeper #2 also stated it had been a little chilly that morning but there was no rain or wind, and it was already light outside. An interview with Nurse #1 on 4/28/22 at 9:46 AM revealed on the morning of 4/25/22 around 6:50 AM, she was alerted by Housekeeper #1 that a resident was lying on the ground outside near the loading dock at the back of the building. Nurse #1 observed Resident #1 lying on his left side on the handicap ramp by the dumpster near the loading dock. The Administrator, Housekeeper #1, and Housekeeper #2 were all standing around Resident #1. Nurse #1 asked Resident #1 how he got outside, and he pointed towards the two exit doors behind the cooler on the loading dock. Nurse #1 stated she thought Resident #1 was confused because it didn't make sense to her how he could have gotten out of either door that he pointed to. Resident #1 also kept on saying that he needed to go to work. Resident #1 was wearing red tennis shoes, gray sweat pants, black pullover t-shirt and a green jacket that was zipped up. He did not have his glasses on when she observed him. After assessing Resident #1 and making sure it was safe to move him, Housekeeper #1 obtained Resident #1's wheelchair which was still inside his room. They assisted Resident #1 to his wheelchair and brought him inside the building and into his room. As they brought him back inside, they asked him again how he exited the facility and he pointed to the nearest door where they found him which was the door by the time clock. Nurse #1 stated she didn't think Resident #1 could have gotten out of that door either because it was controlled by a keypad where you have to enter a code in order to lock or unlock it. She completed a full body assessment and observed abrasions to Resident #1's elbows. She did not observe any other signs of significant injuries. His blood pressure was a little elevated, but it wasn't abnormal for him. Nurse #1 stated Resident #1 had not tried to get out of the facility before and he never walked around without pushing his wheelchair. She remembered the weather that morning to be comfortable for her even without a jacket and it wasn't raining or windy. An observation on 4/28/22 at 10:09 AM with Nurse #1 of the handicap ramp where Resident #1 was found on 4/25/22 revealed it was approximately 50 feet to the nearest door. The path to the door was curved but paved with a slight incline. The ramp was about 20 feet away from the loading dock and led straight to the back parking area. Another side walk approximately 100 feet away led to the West hall exit door which was found unlocked after the elopement incident. There was a grassy area next to the paved side walk. The facility was surrounded by a wooded area and approximately 100 feet from the handicap ramp was a paved walkway that led directly to the church parking lot next to the facility. The 4-lane main road with a posted speed limit of 45 mph (miles per hour) was approximately 500 feet from the back of the facility where Resident #1 was found. An interview with the Administrator on 4/28/22 at 11:53 AM revealed Resident #1 was found outside at the back of the facility on 4/25/22 around 6:45 AM. Staff identified him and then they came to him for help. They worked to get him back inside the facility. Resident #1 stated he was looking to go home. The Administrator stated he did not know if this was normal behavior for Resident #1. When the Administrator went outside, it was obvious to him that Resident #1 fell , and he was lying on his left side. Resident #1 pointed towards the wall cooler and then to the exit door where the time clock was when he asked him how he got out the building. Nurse #1 assessed Resident #1 for any injuries. Once Resident #1 was back inside, the Administrator started interviewing staff members and residents who were there. He stated the resident council president told him that he last saw Resident #1 around 6:00 AM in the hallway walking without his wheelchair. He inspected all the exit doors and found out that all the exit doors were locked except for an exit door on the West hall, which was unlocked, and he observed the switch to be turned down instead of up. The Administrator stated he couldn't determine who had unlocked the West hall door, but the receptionists were supposed to check all the exit doors every 6 hours and he was told by the Receptionist that she had last checked it on 4/25/22 at 6:00 AM and she observed the West hall exit door to be locked. A review of the weather conditions per Weather Underground website revealed the following data for [NAME], North Carolina on 4/25/22 at 5:52 AM: 61 degrees Fahrenheit (F) with no precipitation, South wind speed at 6 miles per hour (mph). The conditions at 6:52 AM were 60 degrees F with no precipitation, South-Southeast wind speed of 5 mph. An observation of the West hall exit door with the Administrator on 4/28/22 at 12:15 PM revealed a code had to be entered on the keypad on the wall right next to the door in order to unlock and lock it. He pointed to a switch that was covered by a plastic cover. The Administrator stated when he inspected all the exit doors, the switch to the West hall exit door was turned down instead of up, indicating that the door was unlocked. He lifted the plastic cover and flipped the switch down. As soon as he lifted the plastic cover, a loud alarm was heard but it stopped right after the plastic cover was replaced. There was enough time to flip the switch down and unlock the door without having to enter a code on the keypad on the wall near the door. He opened the door and an alarm sounded which could only be heard at the keypad and it only sounded while the door was opened. When he closed the door, the keypad alarm stopped but the door was still unlocked because the switch was in the down/override position. A phone interview with Nurse #2 on 4/28/22 at 11:42 PM revealed she took care of Resident #1 on 4/24/22 on the night shift. At the start of the shift, she saw him coming up to his door and looking out into the hallway for Nurse Aide #2 to come into his room. She didn't see him again until 4:30 AM to 5:00 AM when she gave his medications. Nurse #2 stated she had to wake him up to take his medication, but he never said anything to her. Nurse #2 stated she did not know that Resident #1 had exited the facility that morning. Nurse #2 further stated she found out that Resident #1 had exited the building when the Administrator spoke with her after she had given report to the oncoming nurse. A phone interview with Nurse Aide (NA) #2 on 4/29/22 at 4:26 PM revealed she was the NA assigned to Resident #1 during the time of the elopement on 4/25/22. NA #2 stated she wasn't aware that Resident #1 had gotten out of the building until this interview. She couldn't remember what time she last laid her eyes on him that shift but remembered seeing him out of his room when the shift started around 11:30 PM. Resident #1 walked without his wheelchair and sat down on the couch with her and watched the television for a few minutes before going back into his room. NA #2 stated Resident #1 didn't say anything to her, and she was not sure if this was normal behavior for Resident #1 because she only worked on the weekends and was not familiar with Resident #1. NA #2 stated she couldn't say if she noticed any change in Resident #1's behavior that night. NA #2 also stated she did not remember hearing any exit door alarms on her shift. An interview with NA #1 on 4/28/22 at 5:57 PM revealed she worked on the West hall on the night shift (4/24/22 to 4/25/22) and she observed Resident #1 who resided on the North hall walking on the hallway towards her without his wheelchair a little after 12:00 AM. NA #1 asked him where his wheelchair was, and Resident #1 stated he left his wheelchair in his room. Resident #1 sat on the couch by the nurses' station and talked to her. NA #1 stated she noticed Resident #1 was confused because he was looking for his room. Resident #1 was also chattering about something, but she couldn't understand everything that he said. NA #1 explained she got up and answered a call light and by the time she came out of the room Resident #1 had already left. NA #1 stated she did not notify NA #2 or Nurse #2 who were assigned to him about his confusion and that he was walking in the facility, trying to find his room. NA #1 stated she assumed they would see him when he went back to his room. NA #1 stated she did not know that Resident #1 had exited the building. She said she did not hear any exit alarm door sound during the night shift on 4/24/22 or early morning on 4/25/22. NA #1 stated it was hard to hear the code alarm on the West hall exit door whenever the door was opened, and she was working with a resident on the hall with the door closed. A phone interview with Nurse #4 on 4/29/22 at 11:58 AM revealed she worked on the West hall on night shift on 4/24/22. Nurse #4 stated she wasn't familiar with Resident #1 because he resided on the North hall, but she remembered him standing in the North hallway with no wheelchair between 2:00 AM and 3:00 AM in the morning. Nurse #4 motioned for NA #2 to alert her that Resident #1 was standing in the hallway, and NA #2 started assisting Resident #1. Nurse #4 remembered that Resident #1 was wearing his red shoes. She stated she did not see him again that night and she didn't hear any exit door alarms go off. Nurse #4 stated it was hard to hear the code alarms when the exit doors were opened because they only sounded by the door on the keypad. If she was at the top of the hall, she was not able to hear the door alarm sound because it only sounded on the keypad which was right next to the exit door and the alarm wasn't loud. Nurse #4 stated she didn't know Resident #1 had exited the building. A phone interview with the Receptionist on 4/29/22 at 11:40 AM revealed she worked from 7:00 PM on 4/24/22 to 7:00 AM on 4/25/22. She was supposed to walk around the facility and check all the exit doors every 6 hours. The Receptionist stated she checked and made sure all the exit doors were locked at 12:00 AM and again at 6:00 AM. She stated she remembered Resident #1 roaming the hallway while propelling himself in his wheelchair on 4/24/22 around 11:00 PM but he never came to the front door and requested to go out of the facility. An interview with the Maintenance Director on 4/28/22 at 4:24 PM revealed part of his daily routine was checking all the exit doors which he normally did at the start of his shift between 7:00 AM to 8:00 AM. He stated he only worked as on call on the weekends, and he didn't have to come to the facility on [DATE]. He was also off on 4/25/22. The Maintenance Director stated he heard about Resident #1's elopement when he came in to work on 4/26/22 and the Administrator discussed with him his concerns about the West hall door being unlocked from the day before. The Maintenance Director stated he checked all the exit doors to make sure they were functioning, and he determined that they were all functional and were locked when he inspected them at that time. During this interview, an observation of the West hall exit door was conducted with the Maintenance Director. He demonstrated how to unlock and lock the door by entering a code on the keypad on the wall right by the door. After entering the code, he stated the door will open for 15 seconds without an alarm going off. To lock the door back, a code had to be entered again on the keypad. The Maintenance Director motioned to the control switch that was encased by a plastic cover and stated that the switch was a failsafe mechanism that was supposed to be used only for emergency purposes when the code on the keypad won't work to unlock the door. When he lifted the plastic cover, a loud noise was heard but it stopped as soon as the cover was replaced. When he flipped the switch down and opened the door, an alarm went off, but it was only audible right by the keypad. When he closed the door, the alarm at the keypad stopped but the door continued to be unlocked while the switch was down/override position even though the door had been closed back. The Maintenance Director stated staff should be responding to any exit door alarm, but he noticed that didn't always happen. He also stated staff members were not supposed to be using the hall exit doors to enter and exit the facility. He further stated that he just changed the code to the exit door keypads on 4/24/22 and only disclosed it to the Administrator, the Director of Nursing, and the receptionists. A phone interview with the Nurse Practitioner (NP) on 4/28/22 at 1:21 PM revealed she had assessed Resident #1 on 4/25/22 around 10:30 AM after he was found outside on the ground, and she noticed that he was more confused than usual, but he did not show any signs of head injury and she didn't think he needed to go out to the hospital for further assessment. The NP stated she ordered an x-ray of bilateral knees because he complained to her of soreness to both knees. She also ordered bloodwork and urinalysis to see if she could determine the cause of his confusion. The NP also stated she didn't think it was safe for him to be outside and unsupervised due to his cognitive deficits. An interview with the Director of Nursing on 4/28/22 at 11:31 AM revealed she was not sure how Resident #1 had exited the building because all the doors were supposed to be locked. Based on her investigation, Resident #1 was last seen inside the facility on 4/25/22 around 4:30 AM when Nurse #2 administered his medications. A follow-up interview with the Administrator on 4/28/22 at 5:28 PM revealed he started the exit door check sheet on 4/6/22 because he had been finding exit doors that were unlocked. He decided the receptionists could do them since they were at the facility 24 hours a day. He identified that a possible way that Resident #1 got out of the facility was through an exit door that was unlocked, and he needed everyone to assist him in making sure all exit doors were locked. On 4/26/22, he communicated to all staff to make sure all the doors were locked outside the times that the receptionists were checking the exit doors. The Administrator stated the exit door checks used to be every 6 hours until 4/25/22 after Resident #1's elopement when he changed it to every 4 hours. Starting 4/26/22, he inspected the exit door check sheets daily and talked to the receptionists about any issues with any unlocked doors. He also told all staff not to use any of the exit doors and to only use the front door to enter and exit the facility. The Administrator was informed of Immediate Jeopardy on 4/29/22 at 2:22 PM. The facility provided the following Credible Allegation of IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The annual MDS dated [DATE] indicated Resident #1 was severely cognitively impaired. On 4/25/22, Resident #1 exited the facility unsupervised sometime after 6:00 AM. He was discovered on the ground outside the back of the facility at 6:44 AM. After the investigation, it was determined that Resident #1 could have opened the West wing door to enjoy weather and was able to exit the building unsupervised. This occurred as a result of the door lock being placed in an override position and floor staff unable to hear the alarm indicative of door being open. Resident #1 was noted by Nurse #2 to be in his room at approximately 4:30 AM as she administered AM medication to him. Resident #2 (resident council president) noted seeing Resident #1 in the hallway after 6:00 AM. Approximately 6:44 AM, Housekeeper #1 noted seeing Resident #1 outside in the back parking lot lying on the ground as he was coming into work. Resident #1 was appropriately dressed for the season. Approximately 6:47 AM, Housekeeper #1 communicated with the Administrator that he saw resident outside. Administrator went outside with Housekeeper #1 and found Resident #1 alert while on the ground wearing a jacket, t-shirt, sweatpants, shoes, and hat. Administrator communicated for housekeeper to go inside nursing home and request a nurse. Approximately 6:50 AM, Nurse #1 went outside, asked the resident questions, and assessed resident for injury. Housekeeper #1 was instructed to bring Resident #1's wheelchair and Resident #1 was escorted back into the facility by Nurse #1 and Administrator. Nurse #1 took resident to his room. A full skin assessment was performed for Resident #1, noted that he had small abrasions, they were cleaned with normal saline and dried. Range of motion was performed and when raising left arm discomfort was noted. There was no evidence of any head injury. Vital signs were obtained and indicated an elevated blood pressure of 138/91, pulse 94, temperature 97.2, oxygen saturation 97%. Nurse Practitioner (NP) & RP (responsible party) notified on 4/25/22. Administrator left voicemail on phone for the guardian of Resident #1 due to no response at the time of call. After the resident was returned inside the facility, he was in a wheelchair within sight at the nursing station (North) for observation. No further wandering behavior noted. On 4/25/22 at 7:20 AM, the Administrator conducted facility door checks to ensure that each door was locked and secure. Administrator noted one door unlocked (West wing). Administrator placed the unlocked door back in locked fashion. The West wing door found to be unlocked was proximate to the location of where Resident #1 was found lying alert on the ground. On 4/25/22 at 7:30 AM, the Director of Nursing Services conducted a facility head count to ensure that all residents were accounted for inside the nursing home. All residents were accounted for, and Resident #1 was noted back in his room. Resident #1 elopement risk assessment was completed by Nurse #1 and updated on 4/25/22. The assessment indicated that Resident #1 was at risk for elopement. Resident #1 behavior care plan was updated by MDS Coordinator to reflect the unsupervised exit on 4/25/22. Resident #1 had never had a need for an elopement care plan prior to date 4/25/22 due to no documented history of wandering behavior. On 4/25/22 during the Nurse Practitioner's initial assessment of Resident #1, he was found to be awake and alert but with increased confusion from baseline. The patient denied hitting his head during the fall and denied having any headache and the NP did not determine that there was a need to send patient out to the emergency department. Later in the morning, Resident #1 became less responsive and was sent to the emergency department for evaluation and treatment. On 4/25/22, all current census residents were reassessed for exit seeking behaviors. This included completing a new elopement assessment. This task was completed by the Director of Nursing Services and administrative nurses and finalized on 4/29/22. This also included ensuring that each resident who was identified as high risk for elopement had a care plan to address their behaviors. On 4/25/22, all elopement binders were audited by Unit Managers to ensure that they were up to date with current residents with high risk for elopement. These binders were located at the front desk and at each nursing station. These books contained the list of residents with exit-seeking behaviors, their pictures and residents' description. On 4/28/22, care plans were updated for all additional residents who triggered for at risk for elopement by the MDS nurse. In total 6 residents were identified with wandering behavior which caused them to be at risk for elopement. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: All residents upon admission, quarterly, and at a significant change of condition are evaluated for elopement risk by the administrative nursing team during clinical morning meeting and weekly standard of care. The assessments identify deficits in cognitive, diagnosis, ADL (activities of daily living) impairment, and/or history of elopement behavior. At the time of identifying a resident at high risk, the facility Director of Nursing and/or administrative nurse will update their elopement books that are located at each nurses' station and at the front desk. Facility staff receive training on the updates to the Elopement Manual. This is already a process, and it will continue. 4/26/22, Education on Door Alarms and the response to alarms was completed by the Administrator and/or administrative designee to all staff, including agency, all departments. Education also includes ensuring staff door securement response is vigilant by all staff making sure all exit doors are locked and only utilizing one entry and exit from the facility that being the front entrance to the facility. Current staff, including agency will not be allowed to work until they have completed this training. No staff members who have not received the education will work until they complete the education. Administrator and/or administrative designee are responsible for the tracking of 100% compliance. As staff come into work the Administrator and/or administrative designee determines which staff have not done in servicing using a logged staffing roster for all staff, all departments and those not displayed are provided the necessary education and sign documentation. Human Resources will ensure all new hire orientation on door alarm education and elopement policy. 4/29/22, Administrator and/or administrator designee provided education to current nursing staff, including agency staff, all departments related to the Elopement Policy. Education includes the facility policy for elopement or suspected elopement, signs/symptoms of elopement risk, supervision of residents with exit seeking behavior and intervention strategies, and elopement booklet locations. Resident safety is the responsibility of all staff. At the time of a door alarm sound the staff member at the door site will immediately initiate an extensive search of the surrounding outside area. Any staff member who becomes aware of a missing resident will alert all personnel using the facility approved protocols (internal alert code: code AMBER). A head count will be immediately prompted to ensure 100 percent of residents are accounted for. It is the responsibility of all staff, regardless of the department they work in, to respond to activated door alarms and to return residents to their units. Staff should promptly report any resident who exhibits elopement or wandering behaviors to the charge nurse or Director of Health Services. Staff will coordinate search teams with resident identification for a resident not found in the building or on the grounds or on an authorized leave, notify the Administrator, legal representative, attending provider and law enforcement officials. Current staff, including agency will not be allowed to work until they have completed this training. No staff members who have not received the education will work until they have completed this training. No staff members who have not received the education will work until they complete the education. Newly hired staff will receive this education during orientation. Administrator and/or administrative designee is responsible for the tracking of 100% compliance. As staff come into work the Administrator and/or administrative designee determines which staff have not done in servicing using a logged staffing roster for all staff, all departments and those not displayed are provided the necessary education and sign documentation. Human Resources will ensure all new hire orientation on door alarm education and elopement policy. The Maintenance Director will complete elopement drills monthly for 3 months then ongoing quarterly thereafter utilizing the Elopement Drill and Event Worksheet. Elopement drills have been a routine quarterly drill conducted by the Maintenance Director. The Administrator implemented on 4/29/22 an ongoing every 15-minute monitoring of the exit doors to ensure that the door lock has not been placed in an override position. These rounding efforts will be documented and reviewed on an ongoing basis. Facility exit doors will be monitored by receptionists and/or designee every 15 minutes daily for 4 weeks, then weekly for 10 weeks. The Maintenance Director checks the doors daily as a regular preventative maintenance task Monday through Friday to determine functionality of the lock and the door alarms. All receptionists and other specific designees were appointed by Administrator to complete every 15-minute daily monitoring checks. On 4/29/22, the Administrator completed education to all designated receptionists and other specific designees on every 15 minutes daily monitoring. On 4/29/22, Administrator coordinated a visit with the door alarm contractor to increase the volume of West wing door alarm. On 4/30/22, the door alarm contractor came and reviewed the West wing door identified as softly beeping and reprogrammed the door and another that was found not loud enough by the Maintenance Director on 4/29/22. The Maintenance Director audited all exit doors on 4/29/22 for which doors needed a volume level increase. During the morning clinical meeting the Director of Nursing will review incident reports, resident progress notes, and 24-hour report to identify any new behaviors of wandering or exit seeking by current residents. This is a new process for the facility morning clinical meeting. Alleged date of IJ removal: 5/1/22 The credible allegation for the immediate jeopardy removal was validated on 05/05/22 and the immediate jeopardy removal date of 05/01/22 was confirmed. Elopement books were observed to be at each of the nurses' stations and the front desk and included a picture and description of the residents currently identified at risk for elopement. [TRUNCATED]

Based on record review, observation and interviews with resident, staff, guardian, Wound Family Nurse Practitioner and physician, the facility failed to: assess and document wounds consistently; provide wound treatments as ordered; and provide pressure relief from equipment that operated in accordance with manufacturer ' s instructions. These failures led to the development of new wounds, wounds that worsened in size and became infected (#6 and #15), and wounds that resulted in hospital interventions. These problems affected 2 of 3 sampled residents with pressure ulcers. Resident #6 developed a new pressure ulcer on the elbow, developed larger wounds on the hips and sacrum that became infected, acquired [CONDITION(S)] of the toe and expressed pain from inadequate pressure relief while in bed. Resident #6 required hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 developed a new wound that advanced to the highest stage with infection. This resulted in surgical debridement and hospital treatment. Immediate jeopardy began on 9/22/21 for Resident #15 when the facility failed to provide ongoing assessment for skin abrasion of his buttock which resulted in a black necrotic unstageable pressure ulcer the size of a fist that required surgical debridement. Immediate jeopardy began on 10/11/21 for Resident #6 when his right toe unstageable ulcer required debridement and antibiotics. Immediate jeopardy was removed on 11/7/2021 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: 1. Resident #6 was admitted to the facility on [DATE] with muscle weakness and pressure ulcers to his right and left ischium and sacrum. Resident #6 ' s admission Minimum Daily Set (MDS) dated [DATE] documented he had an intact cognition. He had bowel incontinence. He had one stage 4 pressure ulcer and 6 unstageable pressure ulcers with suspected deep tissue injury. Resident #6 ' s quarterly MDS dated [DATE] documented he had 2 stage 3 pressure ulcers, 3 stage 4 pressure ulcers, and 3 unstageable pressure ulcers with suspected deep tissue injury. He had bowel incontinence. Resident #6 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack with wet Dakin ' s 0/5% solution gauze and cover with dry sterile dressing (DSD). Resident #6 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack with wet Dakin ' s solution gauze and cover with dry sterile dressing (DSD). Resident #6 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack with wet Dakin ' s solution gauze and cover with DSD. Resident #6 ' s care plan last updated for pressure ulcers on 9/21/21 documented that he had pressure ulcers to his left heel, right toes, left elbow, bilateral ischium, and sacrum. The right toes all had black necrotic tissue, unstageable, and scabbed (stable). Interventions for pressure ulcers were pressure reduction device and turning. Resident #6 ' s pressure ulcer reduction bed was to enhance healing and prevent skin breakdown. The manufacturer instructions indicated close supervision was needed when used by a person with disability. The mattress inflation level was according to the person ' s weight and comfort level in conjunction with the physician. The manufacturer ' s comfort and weight level table provided the inflation recommendation by the person ' s weight. Service and malfunction will light for malfunction of the mattress. Warning: the pump unit should always be operating to prevent bedsores from occurring. The wound care family nurse practitioner progress note dated 9/9/21 documented Resident #6 ' s wound to sacrum was stage 4 and had length 6 centimeters (cm), width 3 cm, and depth 2 cm. There was no tunneling (opening under the skin in one direction) and there was moderate serosanguinous drainage and undermining (opening under the skin in more than one direction) at 9 o ' clock of 1.1 cm. The wound to his left ischium was stage 4 had length 3 cm, width 2.1 cm, and depth 1.2 cm. There was yellow necrotic tissue with minimal serosanguinous drainage. The wound to his right ischium was stage 4 had length 3.8 cm, width cm 1.5, and depth 1 cm. There was yellow necrotic tissue. There was no tunnel for either ischium pressure ulcer but slight odor. The ischium and sacral ulcers had improved. Right toes all had black necrotic tissue, were unstageable, and scabbed. The wound care family nurse practitioner progress note dated 9/20/21 documented Resident #6 ' s left elbow was an unstageable skin tear and had length 2.5 cm, width 1.6 cm, and depth 0.1 cm. No tunneling was observed and had mild serous draining. The sacrum wound was stage 4 and had length 6.1 cm, width 3.4 cm, and depth 1.9 cm. There was undermining at 9 o ' clock at 1.1 cm. No tunnel observed and had yellow necrotic tissue. There was moderate serosanguinous drainage with moderate odor. The left ischium was a stage 4 pressure ulcer and had length 2.9 cm, width 2.0 cm, and depth 1.1 cm. No tunneling was observed. Yellow necrotic tissue was present. Status: sacral and ischial wounds were improving. Right toes all had black necrotic tissue and unstageable. Resident #6 ' s treatment administration record (TAR) for October 2021 revealed several treatments were not signed as completed. The right toes had an order dated 6/20/21 to paint with [MEDICATION(S)] each day scheduled at 2:30 pm: dates 10/1/21 - 10/4/21 and 10/6/21 - 10/10/21 had no initials documented for care completed. The right ischium had an order dated 7/22/21 to cleanse and pack with wet Dakin ' s 0.5% solution (antiseptic medication) and cover with a DSD. There were no initials entered for care completed on the 2:30 pm block for 10/1/21 - 10/4/21 and 10/6/21 - 10/10/21. The left ischium had an order dated 7/22/21 to cleanse and pack with wet Dakin ' s 0.5% solution and cover with a DSD. There were no initials entered for care completed on the 2:30 pm block for 10/1/21 - 10/4/21 and 10/6/21 - 10/10/21. The sacrum had an order dated 7/12/21 to cleanse with wound cleanser daily wet Dakin ' s 0.5% solution and cover with a DSD. There were no initials entered for care completed on the 2:30 pm block for 10/1/21 - 10/4/21 and 10/6/21 - 10/10/21. On 10/28 at 5:25 pm an interview was conducted with Nurse #1. Nurse #1 stated the TAR was not initialed because the wound care was not done. A nurses ' note dated 10/11/21 documented that the facility nurse practitioner observed Resident #6 ' s pressure ulcers and determined that the right toe declined and appeared infected. An order to send the resident to the hospital was provided. Resident #6 was hospitalized from 10/11/21 until 10/18/21 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The hospital discharge summary dated 10/18/21 for Resident #6 documented that the resident ' s right toe was infected, and he had acquired an [CONDITION(S)] (infection of the bone) to that toe. The resident remained admitted for intravenous antibiotics and was discharged back to the facility with continued antibiotics. The ischiums and sacral pressure ulcers were stage 4. Resident #6 ' s TAR documentation after readmission to the facility was as follows. The left elbow had an order to cleanse, apply calcium alginate, and cover with DSD. There were no initials entered for care completed on the 2:30 pm block for 10/20/21 - 10/25/21 and 10/29/21. The right 5th toe had an order to paint with [MEDICATION(S)] daily. There were no initials entered for care completed on the 2:30 pm block for 10/20/21 - 10/25/21 and 10/29/21. The right ischium had an order to cleanse and pack wet with Dakin ' s solution and cover with DSD daily. There were no initials entered for care completed on the 2:30 pm block for 10/20/21 - 10/25/21 and 10/29/21. The left ischium had an order to cleanse and pack wet with Dakin ' s solution and cover with DSD daily. There were no initials entered for care completed on the 2:30 pm block for 10/20/21 - 10/25/21 and 10/29/21. The sacrum had an order to cleanse with wound cleanser, pack wet with Dakin ' s solution and cover with DSD. There were no initials entered for care completed on the 2:30 pm block for 10/20/21 - 10/25/21 and 10/29/21. On 10/28 at 5:25 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned two nursing units due to lack of staff on 10/10/21 and 10/24/21 for day shift 7 am to 3 pm. Nurse #1 was asked to stay for one nurse assignment for evening shift 3 pm to 11 pm due to a lack of staffing on the same days. Nurse #1 stated that her additional day shift assignment included Resident #6 ' s wound care. Nurse #1 stated that she was not able to provide wound care and supervision (to include checking Resident #6 ' s air mattress inflation device for appropriate pressure) to any of the residents on the additional assignment, which included Resident #6 ' s wound care. Total residents for both nursing assignments were more than 30 residents. The treatment administration record (TAR) was not initialed because the care was not done. Nurse #1 stated that she informed the Director of Nursing (DON) on both occasions. Nurse #1 stated that a lack of staffing was an ongoing problem and management was aware that care was not being completed. Nurse #1 was aware that 10/10/21 and 10/24/21 were not the only days in October 2021 that had insufficient staff and care was not completed as reflected in the blank TAR documentation. On 11/4/21 at 2:10 pm an interview was conducted with the DON and Corporate Nurse Consultant. Both staff stated after a review of Resident #6 ' s TAR documentation for October 2021, if the resident was out of the facility there would be a star in the initial box and if there were no nursing staff initials documented, the care was not completed due to insufficient staffing. The DON stated she was made aware that wound care was not completed as ordered, not always when it happened. The DON stated that for the first three weeks in October 2021 the wound care family nurse practitioner was not available, and the assigned residents ' wounds were not assessed and measured during this time. The DON stated that there was not a wound care nurse and assigned nursing staff had not measured the resident ' s wounds during October. Resident #6 ' s quarterly Minimum Data Set, dated dated dated [DATE] documented five stage IV pressure ulcers with four present on admission and 1 unstageable pressure ulcer. Resident #6 ' s weight was 168 pounds. The care plan was not updated after hospitalization . The wound care family nurse practitioner progress note dated 10/26/21 documented right elbow pressure ulcer (started as a skin tear) had length 2.6 cm, width 0.8 cm, and depth 0.1 cm. There was scant serous drainage, and the wound was declining. Sacral wound had length 7.3 cm, width 5.1, and depth 3.2. There was a tunnel of 6.4 cm (new). Around the wound was red. There was yellow necrotic tissue and moderate foul-smelling drainage. The wound was declining. The left ischium had length 4.5 cm, width 4.4 cm, and depth 3.4 cm. Around the wound was red. There was yellow necrotic tissue with minimal serosanguinous drainage. The wound was declining. The right ischium had length 4.1 cm, width 4.2 cm, and depth 3.1cm. Around the wound was red. There was yellow necrotic tissue with minimal serosanguinous draining. The wound was declining. Right foot toes: 2nd, 3rd, and 4th toes were now open and declining. There was 100% necrotic tissue with no drainage. On 10/28/21 at 10:10 am an observation was done of Resident #6 in his pressure reduction air mattress bed. The resident was slightly off to his left leaning on his left elbow. Observation of the air flow pressure device for the mattress indicated a red light on maintenance and the light for pressure by weight had indicated less than 100 pounds (lbs). The resident had a wound dressing to his left elbow, bilateral shins, and right heel and foot. Both legs were edematous. The resident ' s heels were off the bed. The air mattress was soft to the touch, pressure was below 100lbs and then disappeared on the indicator. On 10/28/21 at 10:40 am an interview was conducted with Resident #6. The resident complained that his sacral pressure ulcer was hurting and thought the mattress was soft and had been soft. The resident did not know why. He stated that he had several open areas in his skin. The resident stated that his dressings were not always changed. The resident stated that he had received his pain medication but was uncomfortable on the bed. On 10/28/21 at 12:15 pm an observation was done of Resident #6 in his pressure reduction air mattress bed. The resident was slightly off to his left leaning on his left elbow. Observation of the air flow pressure device for the mattress indicated a red light for maintenance and the light for pressure by weight was indicating less than 100 lbs. On 10/28/21 at 2:40 pm an observation was done of Resident #6 in his pressure reduction air mattress bed. The resident was slightly off to his left leaning on his left elbow. Observation of the air flow pressure device for the mattress indicated a red light for maintenance and the light for pressure by weight had indicated less than 100 lbs On 10/28/21 at 4:10 pm an interview was conducted with Nurse #4 who was assigned to Resident #6. She stated she was in earlier to check Resident #6 ' s air mattress control box to see if it was lit. She was not aware that the device had a maintenance red light lit. She did not know who would trouble shoot/fix the mattress air pressure and would need to inform maintenance. She stated that the resident does not like to be turned because it caused him pain. On 10/28/21 at 5:10 pm an observation was done of Resident #6 on his pressure reduction air mattress bed. The resident was slightly off to his left leaning on his left elbow. Observation of the air flow pressure device for the mattress indicated a red light on maintenance and the light for pressure by weight was indicating less than 100 lbs. On 10/29/21 at 6:45 am an observation was done of Resident #6 in his bed. The pressure reduction air mattress was inflated, and the pressure monitor red maintenance light was no longer lit. The pressure light indicated it was set at 1000 lbs. On 10/29/21 at 7:00 am an interview was conducted with Nurse #6 night-shift nurse assigned to Resident #6. She stated she looked at the air mattress control device to make sure it was lit and observed the control device during interview. (Nurse #6 was not aware that it was set to 1000 lbs). On 10/29/21 at 7:55 am an interview was conducted with the Activities Coordinator/Medication Aide (AC/MA). She was assigned to Resident #6 for day shift. She stated the resident was on a pressure reduction air mattress and looked at the pressure regulation device at the end of the bed, not just that it was lit but that it was providing proper pressure. The setting was set to 1000 lbs. She observed the pressure device during interview and had not commented if the pressure was set at the proper setting for the resident. On 10/29/21 at 11:10 am an observation was done of Resident #6 ' s wound care. Care was provided by Nurse #7. She commented that the pressure ulcers to the sacrum and 2 ischiums were deep and without signs and symptoms of infection. Nurse #7 observed and unlocked the pressure reduction mattress because the setting was at 1000 lbs. Nurse #7 changed the setting to 200 lbs to match up closer to the resident ' s weight. The resident was noted to sink in the center almost to the frame of the bed. Nurse #7 stated that there was an air mattress beneath the resident ' s torso. The DON entered the room and took a picture of the air mattress pressure device and serial number. The DON commented that the air mattress device was broken and would need to be replaced. The DON commented that 1000 lbs was not the correct pressure for Resident #6. On 10/29/21 at 12:10 pm an interview was conducted with the DON. The DON stated she did not know the air mattress device was not working until today and she did not know how long it had not been operating correctly. Staff had not reported that the mattress was in maintenance mode. The DON was aware that Resident #6 ' s pressure ulcer had declined and that the pressure reduction bed was part of the resident ' s plan to prevent further pressure ulcer. She said the bed would be replaced. On 10/29/21 at 1:40 pm an interview was conducted with the wound family nurse practitioner for Resident #6. She stated that Resident #6 was assessed and measured on 10/26/21 and all pressure ulcers had declined. She stated that an inoperable pressure reduction bed that was too soft or too hard would not provide pressure reduction and would harm frail, pressure ulcerated tissue. She stated that Resident #6 was a high risk for infection and [CONDITION(S)] and daily wound care was important to prevent infection. She stated that without pressure reduction and wound care the wounds would be expected to decline. She stated she was aware that there were no assessments and measurements of the residents that were being followed for wound for the prior 3 weeks to the 10/26/21 visit, staff was unavailable. On 11/1/21 at 10:32 am an interview was conducted by telephone with the facility physician. He stated that an air mattress pressure reduction bed was for pressure reduction. If the mattress was too soft or too hard (not operating), it would cause undue pressure and injury. On 11/4/21 at 11:10 am an interview was conducted with the facility physician. He stated that if the wound care was not completed as ordered or missed, the wound could become infected or worsen (larger). He stated that he was not made aware that Resident #6 ' s wound care was not completed as ordered and was aware that the resident was hospitalized for his pressure ulcer infection in October 2021 (10/11/21 to 10/18/21) and was aware that all the pressure ulcers had declined (wound nurse practitioner visit of 10/26/21). He stated that residents informed him they waited for wound care and the assigned nurse informed the resident they would return but had not returned. He stated that the failure to provide wound care for Resident #6 contributed to his infection. 2. Resident #15 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #15 ' s quarterly Minimum Data Set, dated dated dated [DATE] documented an intact cognition. His active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 ' s admission Braden Scale documented he was a high risk for pressure ulcer. Resident #15 ' s care plan documented a problem onset dated 5/9/19 at risk for pressure ulcers related to his diagnosis, immobility, and incontinence. Interventions included weight shift and daily observation of skin. Resident #15 ' s nurses ' note written by Nurse #9 dated 9/22/21 documented right buttocks (ischium) open area noted that went from skin abrasion to stage 2 quickly, in a matter of days. The wound had declined with necrotic tissue. Resident #15 was planned for surgical consult. A new order Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/5/21 at 3:00 pm an interview was conducted with Nurse #9. She stated that she was assigned to Resident #15. She had identified the skin abrasion to the ischium which she covered with a DSD that was now a stage 2 and Medi-honey and dressing was ordered for each day. On 9/22/21 Nurse #9 stated she observed Resident #15 ' s ischium wound which had declined to a black necrotic unstageable pressure ulcer the size of her fist. The facility nurse practitioner was informed of the wound decline and assessed the resident by video. The facility nurse practitioner gave orders for a surgical consult: concern for infection and needed debridement of eschar tissue. Nurse #9 informed the nurse practitioner that Resident #15 had not received wound care on several occasions in September 2021. Nurse #9 stated that she was aware that wound care was not being completed due to insufficient staffing and observed on the North Unit that staffing had not completed wound care even when staffed. Nurse #9 would round with the wound care nurse practitioner each week and reviewed the TAR. Nurse #9 stated that the wound care was not initialed as being completed for several residents. After Nurse #9 stated she inquired why there were no initials, she was informed by nursing that the care was not completed. Nurse #9 stated she informed the Director of Nursing (DON) of the failure to provide wound care to multiple residents on multiple dates during the month of September 2021. Nurse #9 stated that the failure to provide wound care was discussed in the morning stand up meeting (daily clinical meeting where management was present). Nurse #9 stated that the facility was aware that wound care was not being completed. Nurse #9 had changed her employment status to as needed and had not been back in the facility since 10/1/21. Resident #15 ' s Treatment Administration Record (TAR) for September 2021 documented care for right buttock as ordered starting on 9/23/21 at 2:30 pm. There were no initials on the TAR to indicate care was provided for the dates of 9/23/21 - 9/26/21. Resident #15 ' s TAR for October 2021 documented care for right buttock as ordered at 2:30 pm. There were no initials for care provided dated 10/1/21 - 10/6/21 (star in signature/initial block for remainder of the month for 10/7/21 hospitalization ). Resident #15 ' s nurses ' note dated 10/6/21 documented he was sent out for surgical consult of the pressure ulcer stage 5 ischium wound per the wound nurse practitioner. Resident #15 ' s discharge MDS dated [DATE] documented an intact cognition and stage 4 (ischium) pressure ulcers. Resident #15 ' s hospital history and physical dated 10/7/21 documented inpatient admission for a worsening pressure ulcer now a stage 4 with deep wound infection. Plan for operative debridement. Resident #15 ' s facility nurse practitioner ' s progress note dated 10/11/21 for follow-up on sacral wound after debridement documented there was skin breakdown to sacrum and right buttocks. The resident ' s wound was examined last week (before debridement), and it had black eschar circular of right buttock and there was evidence of purulent drainage on his dressing. Resident was sent to the hospital for debridement for the black eschar and purulent drainage (10/7/21). The wound tissue was now pink with serous drainage and was packed with gauze and no current signs of infection. The resident had an elevated which cell count while in the hospital. Resident #15 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 ' s October TAR for wound care order beginning 10/11/21 documented no initials for care provided 10/11/21 pm - 10/15/21 for twice a day dressing, no initials for 10/17/21 - 10/18/21 twice a day dressing, no initials for 10/20/21 - 10/22/21 for twice a day dressing, and no initials for 10/23/21 in the pm. Resident #15 ' s facility nurse practitioner progress note dated 10/18/21 documented follow up for decubitus ulcer. Approximately 2 weeks ago the resident had surgical debridement. She ordered wound care nurse practitioner to follow closely. Order for Dakin ' s solution cleanse and pack with Dakin ' s wet-to-dry dressing twice a day. A review of Resident #15 ' s medical record had no documentation of care by the wound care nurse practitioner. Resident #15 ' s physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital. Resident #15 ' s discharge summary dated 10/28/21 documented the resident ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Antibiotic coverage was provided. Suspected sacral ulcer infection. Hospital physical therapy recommended a motorized wheelchair to get the resident up off his sacral ulcer. Resident #15 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 ' s TAR for October of 2021 order began 10/28/21 had initials for care provided except for 10/28/21 10:30 pm and 10/30/21 2:30 pm. On 11/3/21 at 2:02 pm an interview was conducted with the Guardian/RP (responsible party) for Resident #15. The RP stated that the resident acquired a pressure ulcer in September that quickly worsened. The resident had informed her his wound care was not being completed regularly and he was not getting out of bed. The resident has had to have two debridements to his ischium/sacral pressure ulcer due to infection and necrotic tissue which was a change. The resident had advancing disease and was at risk for [CONDITION(S)]. On 11/4/21 at 11:10 am an interview was conducted with the facility physician. He stated that if the wound care was not completed as ordered or missed, the wound could become infected or worsen. He stated that he was not made aware by the facility that Resident #15 ' s wound care was not completed as ordered and was aware that the resident required debridement. He stated that residents informed him they waited for wound care. The assigned nurse stated to residents they would return and had not returned when I saw the resident later in the day. The physician did not indicate which residents informed him. He stated that a failure to provide wound care would be a contributor to infection. The physician was informed that an interview with the facility nurse practitioner that he supervised would need to be interviewed. An interview was attempted with the facility nurse practitioner on 11/4/21 and 11/5/21. Message was not able to be left, the mailbox was full. The supervising facility physician was informed on 11/4/21 by telephone message and no return call was provided from the facility nurse practitioner or physician. On 11/4/21 at 2:10 pm an interview was conducted with the DON and corporate nurse consultant. Both staff stated TAR documented if the resident was out of the facility there would be a star in the initial box and if there were no nursing staff initials documented, the care was not completed due to insufficient staffing. The DON stated she was made aware that wound care was not completed as ordered, but not always when it happened. The DON stated that for the first three weeks in October 2021 the wound care family nurse practitioner was not available, and the residents ' wounds were not assessed and measured during this time. Resident #15 was not seen by the wound care nurse practitioner. The DON stated that there was not a wound care nurse and assigned nursing staff had not measured the resident ' s wounds during the first three weeks in October. Assigned nursing staff were responsible to provide wound care as ordered and there was no replacement for the wound care practitioner ' s assessment and measurement. On 11/4/21 at 2:05 pm an interview was conducted with Resident #15. He stated that he had a wound to his backside that had recent surgery. He stated that the staff does not always change his dressing, they missed some. He stated that he had not gotten up because his wheelchair was too small, and he needed to lean back which caused him to be stuck in bed. The resident stated the surgeon informed him he should be getting up to relieve pressure on his backside. On 11/4/21 at 2:05 pm an observation was done of Resident #15. He was in his bed with an egg-crate mattress (foam mattress). The resident was large and filled the bed. There was a pressure reduction cushion on the wheelchair. The wheelchair appeared to be too narrow for the resident ' s width and had no option to lean back. The Administrator was notified of the immediate jeopardy on 11/5/2021 at 7:12 pm. On 11/6/2021 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following: Allegation of Compliance F 686 Pressure Ulcers The facility failed to provide sufficient nursing staff to ensure residents received consistent pressure ulcer wound care as ordered which resulted in wound decline, infection, needed surgery, and antibiotic administration. (Residents #6 and #15). Resident #6 was readmitted with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . TARS reveal scattered missing wound treatments during the last month. He was discharged to the hospital on 10/11/21 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/29/2021, it was noted that his air mattress had malfunctioned, and it was replaced. Resident # 6 was assessed for current wounds and treatments on 11/5/2021 by wound nurse practitioner, treatment nurse and nurse consultant. Treatment orders are to continue at this time, after reevaluation. Air mattress is functioning properly and checked every shift for continued function and resident is noted to be comfortable during wound evaluation. Resident #15 was originally admitted on [DATE] with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound was noted on 9/22/2021 to extend to the right ischial area with identification of the right buttock which is noted in the residents ' wound records as a Stage 4. Resident was transferred to the hospital for left sided facial drooping and increased [CONDITION(S)] while participating in therapy. During hospitalization it was noted that resident ' s wound had necrotic eschar and wound was debrided during this hospitalization . Resident was readmitted on [DATE] with new orders for wound which were initiated. Resident was seen by in-house treatment nurse and wound nurse practitioner on 11/05/2021. Resident was comfortable and had no pain with treatment provided. Air mattress initiated and functioning properly on 11/06/2021. The Facility currently has a total of ten (10) residents with wounds, as of 11/05/2021. The Facility has employed a Full-Time wound Nurse for the facility 11/5/2021. The Corporate Clinical Nurse completed a Competency with the facility wound nurse and Director of Nursing to ensure they were competent in wound identification, measuring, treatments and healing. The Director of Nursing and Administrative Nurses completed a Head- to- toe assessment of current residents on 11/04/2021, to evaluate current skin condition and identify any new skin deficiencies. Any areas identified were cross referenced with resident ' s Treatment Administration Record to ensure treatments were in place and being implemented timely. Any new areas that would have been identified the resident ' s attending physician would have been notified and treatment order obtained. There were no new areas noted. 11/4/2021, Regional Clinical Nurse completed a review of nurse ' s notes, for the last 30 days. No new concerns were noted. This included, an audit of the previous weeks ' wound progress notes, reviewed for current wound orders and were updated as applicable. This also included updating resident care plans and care guides to ensure interventions fo [TRUNCATED]

Based on record review, observation and interviews of the residents, staff, guardian, and medical staff, the facility failed to provide sufficient nursing staff to 1.) ensure residents received consistent pressure ulcer wound care as ordered and pressure ulcer prevention. for 2 of 3 sampled residents (#6 and #15). 2.) Avoid significant medication errors for 3 of 3 sampled residents reviewed for medication administration (#12, #13 and #14); and 3.) Provide activities of daily living to a resident dependent on staff for nail care and hair washing for 1 of 3 sampled residents (#6). Immediate Jeopardy began on 9/22/21 when there was insufficient staff to carry out wound treatments.for Residents #6 and 15 who both had significant decline to their wounds. The facility did not address insufficient staffing to complete resident ordered wound care and pressure reduction for pressure ulcer prevention. Immediate Jeopardy was removed on 11/7/2021 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to correct findings 2. and 3. and to ensure monitoring of systems are put in place and to complete employee in-service. Findings included: 1. Cross refer to F686. Based on record review, observation and interviews with resident, staff, guardian, Wound Family Nurse Practitioner and physician, the facility failed to: assess and document wounds consistently; provide wound treatments as ordered; and provide pressure relief from equipment that operated in accordance with manufacturer ' s instructions. These failures led to the development of new wounds, wounds that worsened in size and became infected (#6 and #15), and wounds that resulted in hospital interventions. These problems affected 2 of 3 sampled residents with pressure ulcers. Resident #6 developed a new pressure ulcer on the elbow, developed larger wounds on the hips and sacrum that became infected, acquired [CONDITION(S)] of the toe and expressed pain from inadequate pressure relief while in bed. Resident #6 required hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 developed a new wound that advanced to the highest stage with infection. This resulted in surgical debridement and hospital treatment. On 10/28/21 at 1:05 pm an interview was conducted with the Staffing Coordinator/Medication Aide. She stated when staff call out, they were informed to call the Director of Nursing. She stated scheduling nursing staff had been rough over the past couple months and the facility only has approximately 10 employee nursing assistants (NA). The facility has had to use agency staff from 4 different staffing agencies to fill shifts for (licensed nurses and nursing assistants). Currently, the facility is short NA staff, and have approximately 4-5 shifts open on first shift, 2-3 shifts open on second shift, and 3 shifts open on night shift. She stated she would contact the staffing agency 1 to 2 weeks in advance to schedule. Some agency staff cancel. When there were no staff available, the nursing staff would have to take on more residents in their assignment. She stated she worked 16-20 hours a day to help fill in as a medication aide. She stated that she had not been able to schedule a registered nurse for 8 hours each day. When there was not enough staff, she would have to assign licensed nurses about 30 residents and NAs about 20 resident each for their shift. This type of assignment applied to all shifts. On 11/4/21 an interview was conducted with the Administrator. She stated that she was working on contracting with additional staffing agencies to address the facility ' s insufficient staffing problem. There was a job fair planned for 11/5/21. The current contracted agency staff were unreliable and frequently did not show up for their assignment. Part of the new contract plan was for the agency to hold staff accountable when they do not show and to give adequate notice when staff cannot work. The Administrator was notified of the immediate jeopardy on 11/5/2021 at 7:12 pm. On 11/6/2021 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance: The facility failed to provide sufficient nursing staff to ensure resident received consistent pressure ulcer would care as ordered which resulted in wound decline, infection, needed surgery, and antibiotic administration. (Residents #6 and #15). All Residents had the potential to be affected by the alleged deficient practice. The Facility currently has a total of ten (10) residents with wounds, as of 11/5/21. The Facility has employed a Full-Time wound Nurse for the facility 11/5/21. The Corporate Clinical Nurse completed a Competency with the facility wound nurse & Director of Nursing to ensure they were competent in wound identification, measuring, treatments and healing. The Director of Nursing and/or Administrative Nurses completed a Head-to-Toe assessment of current residents on 11/4/2021, to evaluate current skin condition and identify any new skin deficiencies. Any areas identified were cross referenced with resident ' s Treatment Administration Record to ensure treatments were in place and being implemented timely. Any new areas that would have been identified the resident ' s attending physician would have been notified and a treatment order obtained. There were no new areas noted. The facility Director of Nursing and Human Resources has re-implemented a recruiting initiative program beginning 10/30/21 & 11/1/21, for licensed nurses, Certified Medication Aides (CMAs), Certified Nursing Assistants (CNA), this includes utilizing Agency Supplemental Staffing to maintain appropriate staffing numbers, implementing a bonus program for full-time and referral bonus ' for their current licensed nurses, as well as sign-on bonus for new employees. The facility governing body along with Regional Director made the decision, 9/27/21, to stop new admissions to ensure facility stability of current staffing and regulatory concerns. 10/30/21, The facility Director of Nursing and Human Resources is utilizing Certified Medication Aides to assist with Medication Administration with the oversight of a Licensed Nurse, to allow Licensed Nursing staff more time to perform assessments and treatments. Director of Nursing has been having conversations with the licensed nurses about the expectations of the program to be completed by 11/6/21. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete: Executive Director will implement a daily labor meeting that will include, Director of Nursing (DON), Staffing Coordinator, Human Resources, and other members of the Leadership Team, to review current daily staffing needs and forecast the remaining week, including weekends to ensure sufficient staff is available for the resident needs, to include wound care, in the facility. This meeting began 11/5/21. The Corporate Clinical Nurse along with the Director of Nursing, and Scheduler, has completed a master schedule, as of 11/6/21, that will ensure proper staffing levels based on current resident census to ensure that resident wound treatments are completed timely. Director of Nursing has completed re-education with current Licensed Nurses, including Agency staff, If the wound nurse is not available, it will be communicated to the licensed nurses by the Director of Nursing to provide treatments as ordered by the physician. If the licensed nurse cannot complete the treatments within the parameter of their work schedule, the licensed nurse will report the issue to the Director of Nursing and/or facility Executive Director. The Director of Nursing and/or Unit Manager will complete the assessment and measurements. This training will be completed as of 11/6/21, any current nurse, including agency, who is unable to receive this training will not be allowed to work until training is completed by the Director of Nursing and/or designee. New Licensed Nursing staff, including agency, will receive this training at time of their orientation. Resident wound treatments will be validated by weekly observation rounds, 3 times a week, by the Director of Nursing and/or Unit Managers, to ensure treatments are timely and documentation is complete. The Corporate Clinical Nurse will be completing observation rounds, weekly x 4 weeks with the facility clinical staff to provide additional training regarding wound care prevention and treatments. The Director of Nursing and/or Facility Administrator will monitor staffing 5 times a week during the daily Stand-up meeting. The director of nursing and/or designee will monitor the staffing daily 7 days per week to ensure that all call-outs are reported timely and coverage is available. The Facility Administrator will complete a summary of monitoring efforts and present at the monthly Quality Assurance and Performance Improvement meeting, to ensure continued compliance The facility alleges the removal of the Immediate Jeopardy on [DATE], The Administrator and/or Director of Nursing is responsible for assuring corrective actions to ensure continued compliance. The credible allegation was validated on 11/10/21. On 11/5/21 the Corporate Recruiter and facility Human Relations Department completed a job fair at the facility which resulted in 2 new hires, a medication aide and a nurse. An Ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting was held on 11/6/2021. The Executive Director implemented a daily labor meeting. The first meeting was on 11/5/21 and it addressed staffing needs for Friday through Sunday. An 11/8/21 meeting discussed the week ahead and open nursing spots and the 11/9/21 noted 2 new staff members in orientation, 1 medication aide and 1 nurse for night shift. The Corporate Clinical Nurse along with the DON and scheduler had completed a master schedule as of 11/6/21 that would ensure proper staffing levels based on current resident census to ensure that resident wound treatments would be completed as ordered. The Director of Nursing had completed re-education with current licensed nurses, including agency staff was documented. Resident wound treatments had been validated by weekly observation rounds, 3 times a week. The Director of Nursing and/or Facility Administrator had monitored staffing 5 times a week during the daily stand-up meeting. The immediate jeopardy was removed on 11/7/21. 2. Cross refer to F 760. Based on record review and interviews with the staff and Medical Doctor the facility failed to prevent significant medication errors by omitting scheduled doses of a medication used to treat [CONDITION(S)] (Resident #14) and failed to check blood glucose levels to determine if sliding scale [MEDICATION(S)] insulin (a fast-acting antidiabetic medication) was needed and omitted scheduled doses of detemir (a long-acting antidiabetic medication) (Resident #12) and failed to check blood glucose levels and omitted scheduled doses of [MEDICATION(S)] before meals and scheduled doses of detemir (Resident #13) for 3 of 3 residents reviewed for medication errors. 3. Cross refer to F 677. Based on record review, observation, and interview of resident and staff, the facility failed to provide hair wash and nail care to a dependent resident (Resident #6) for 1 of 3 residents sampled.

Based on observations, record review, and staff, resident, Radiologist and Manufacturer Representative interviews, the facility failed to ensure positioning and securement was according to manufacturer recommendations to provide a safe facility van transport for 1 of 5 sampled residents reviewed for accidents (Resident #70). During a facility van transport on 05/17/21, Resident #70 slid partially out of the wheelchair causing his knee and lower legs to hit the floor of the van, resulting in minor bruising noted to his knee and no reported pain. Resident #70 was assisted back to into his wheelchair without an assessment by a licensed nurse or medical professional. On 05/19/21, Resident #70 was sent to the hospital due to increased pain and subsequently diagnosed with a mildly displaced oblique (slanting) fracture of the distal tibia (inner bone between the knee and ankle) and nondisplaced (bone is broken but not out of alignment) fracture of the distal fibula (outer bone between the knee and ankle). Resident #70's leg was placed into a cast secondary to left tibia fracture and he returned to the facility the same day. Immediate Jeopardy began on 05/17/21 when Resident #70 slid out of the wheelchair during a facility van transport and sustained a leg fracture. Immediate Jeopardy was removed on 08/10/21 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: The undated manufacturer's instructions utilized by the facility and titled, Vehicle Anchorages and Accessories for 4-Point Wheelchair Securement Systems, read in part: Securing Wheelchair: Center wheelchair facing forward in securement zone. Attach front retractor or manual front anchorage points and lock them in place. If using deluxe or max retractors, ensure the retractors are used at the front. Completely pull out each webbing and attach J-hook to solid frame member. Attach rear retractors or rear manual tiedowns into floor anchorage points and lock them into place. Completely pull out each webbing and attach hook to solid frame member. Move wheelchair forward and back to remove webbing slack or manual tension webbing with retractor knobs. Lock wheelchair brakes (or power off electric chair). Attach retractable combination lap/shoulder belt: attach tongue on end of shoulder belt to buckle stalk closest to the wall. Pull the shoulder belt over occupant's chest and insert tongue into the buckle stalk closest to the aisle. Adjust shoulder belt height so that shoulder belt rests on occupant's shoulder, making sure the shoulder belt does not rub against the occupant's neck. The manufacturer's instructions provided no guidance regarding occupants sitting on cushions or mechanical lift slings while they were seated in their wheelchair during transport. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses that included an [CONDITION(S)] disease that attacks the central nervous system, muscle weakness and depression. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #70 with intact cognition for daily decision making. The MDS noted he used a wheelchair for mobility, required limited staff assistance with locomotion and total staff assistance with transfers. The Resident Incident Report dated 05/17/21 at 12:00 PM noted Resident #70 slid out of the wheelchair while in the facility van during transport and sustained bruises to the left upper and lower shin that were treated with Topical Antibiotic Ointment (TAO) and dry dressing. The facility's investigation, dated 5/19/21 and completed by the Administrator, revealed in part: on 5/17/21 at approximately 11:30 AM, Resident #70 slid out of the wheelchair while in the facility van being transported back to the facility from an appointment. Resident #70's wheelchair was correctly secured with both chest/lap belt and four-point restraints. However, Resident #70 was noted to have a mechanical lift pad under him and no cushion in the wheelchair. The Transport Driver (TD) #1 was notified by Resident #70 that he was sliding out of the chair, she maneuvered the facility van to a safe location and once the van was stopped, she noticed that Resident #70's upper body (above the waist) was still in the wheelchair being secured by the chest/lap belt and his legs were noted on the floor of the van. Resident #70 was assisted back into the wheelchair by TD #1 and Nurse Aide (NA) #1 and returned to the facility. Nurse #1 was notified of the incident by TD #1 at approximately 12:30 PM and Resident #70 confirmed to Nurse #1 he had slid out of the wheelchair during transport and denied any pain. Upon nurse assessment, it was noted he had bruises to his legs which were cleaned with wound cleanser and TAO and a dry dressing were applied. On 5/19/21, the Nurse Practitioner (NP) was notified Resident #70 complained of pain in his left ankle and orders were received for a 2-view left ankle x-ray. On 5/19/21 at 11:16 PM, TD #1 provided a return demonstration of how Resident #70 was secured in the wheelchair of the facility van and able to demonstrate proper use of the four-point wheelchair restraints and chest/lap securement system. On 5/19/21 at approximately 2:02 PM, x-ray results were received that confirmed Resident #70 had a mildly displaced oblique fracture of the distal tibia and nondisplaced fracture of the distal fibula. Orders were obtained by the NP to send Resident #70 to the ED for evaluation and treatment and he returned to the facility at 11:00 PM with a cast and orders to follow-up with the Orthopedist within one week. The facility's investigation determined the following root causes: a) Resident #70 was moved after a fall in the facility van without a licensed nurse or medical professional assessment, b) Resident #70 did not have a cushion in his chair and had the mechanical lift sling under him which contributed to him sliding out of the wheelchair of the van, and c) Nurse #1 failed to notify the physician of the incident which resulted in a delay of treatment. During an interview on 08/03/21 at 8:52 AM, Resident #70 recalled he was seated in his wheelchair, headed back to the facility in the transport van, when TD #1 slammed on the brakes and he flew forward out of the wheelchair into the dashboard of the van. Resident #70 stated his wheelchair was secure but he did not have a chest or seat belt in place. During a follow-up interview on 08/04/21 at 4:21 PM, Resident #70 clarified when he was seated in the van in his wheelchair, the wheelchair was securely strapped to the floor and now reports he did have the lap/chest belt in place but added the straps were loose and not tight. He stated he was not sure how fast TD #1 was driving but recalled a truck pulled out in front of the van and when TD #1 slammed on the brakes he flew up in the air hitting his knee on the console that was located in between the driver's seat and the passenger seat. Resident #70 denied hitting his head or chest, just his knee which caused the fracture. When asked how he could have reached the console at the front of the van if the lap/chest belt was fastened, he stated it was loose and went with him but never came unfastened. He added the wheelchair then tipped forward to the floor when he landed on the console. When asked how far back he was from the console, he replied 8 to 9 feet and when asked to clarify the distance again, he stated he flew in the air with the lap/chest belt still attached 8 to 9 feet and his knee hit the console. Resident #70 confirmed he did not have a cushion in the seat of his wheelchair prior to or on the day of the incident. During an interview on 08/04/21 at 7:50 AM, TD #1 revealed prior to departure, she made sure Resident #70's wheelchair was secured in the facility van by locking the wheelchair brakes, applying the 4-floor securement locking system to the wheelchair, and attaching the chest/lap belt. TD #1 stated as she was driving down the road, she heard Resident #70 state he was sliding out of the chair, she immediately pulled over to the side of the road and she and NA #1 noticed he had slid down in his wheelchair, with his legs out front and slightly toward the left side and his bottom was still on the edge of the seat with his legs on the floor. She added the chest/lap belt was intact and prevented him from sliding all the way out of the wheelchair. TD #1 recalled Resident #70 had a scratch on the top of his knee that was not bleeding or open and when asked if he was in any pain, he replied 'no.' She added Resident #70 repeatedly asked them to pull me up so both she and NA #1 pulled him back up into the wheelchair, checked to make sure all straps were secure and then continued driving back to the facility. Once back at the facility, TD #1 reported the incident to Nurse #1 and Assistant Director of Nursing. TD #1 explained at the time of the incident she wasn't aware that she should not have moved Resident #70 to reposition him back up straight in the wheelchair after the incident but had since received education that prior to moving a resident after an incident or fall, she was to notify the Nurse. During a follow-up interview on 08/05/21 at 8:43 AM, TD #1 explained Resident #70 had no cushion in the seat of his wheelchair but was sitting on a shower lift sling (one with holes to allow water drainage) underneath his bottom and not the normal fabric mechanical lift sling. TD #1 added normally, when using a mechanical lift to assist a resident into the wheelchair, once the resident was seated, they removed the lift sling; however, she was not sure why facility staff had used the shower sling when transferring him to his wheelchair for transport and felt it was left in his wheelchair to assist hospital staff in transferring him during his appointment. TD #1 restated the van's securement floor straps and lap/chest belt were securely attached to Resident #70's wheelchair prior to leaving the hospital and he never slid all the way to the floor from his wheelchair. TD #1 could not explain how Resident #70 was able to slide out of his wheelchair during transport and stated it was possible the hospital staff had not positioned him correctly in the wheelchair after he was examined. She added there was no vehicle that pulled out in front of the van causing her to slam on the brakes and Resident #70 was not thrust forward hitting the console at the front of the van. During interviews on 08/04/21 at 6:55 AM and 6:15 PM, NA #1 confirmed she had gotten Resident #70 ready for his appointment the morning of 5/17/21. NA #1 explained she couldn't find the normal mechanical lift sling to transfer Resident #70 to his wheelchair so she got one of the shower mesh slings from laundry to use instead. She added, normally she would remove the sling once the resident was placed safely in the wheelchair but left it underneath Resident #70 in case the hospital staff needed to use it to transfer him while at his appointment. NA #1 could not recall if Resident #70 had a cushion in the seat of his wheelchair the morning of 05/17/21. NA #1 verified she was present in the facility transport van with TD #1 and Resident #70 on 05/17/21 when he slid partially out of his wheelchair and confirmed TD #1's statement of what had occurred. She added on the way back to the facility, there was no traffic and no vehicle that pulled out in front of the van causing TD #1 to slam on the brakes nor did Resident #70 fly forward out of his wheelchair from the back of the van and hitting the front console. During a telephone interview on 08/04/21 at 6:23 PM, Nurse #1 stated once Resident #70 returned from his appointment on 05/17/21 she was notified by TD #1 that he had slid partially out of his wheelchair during transport. TD #1 reported to her that Resident #70 was repositioned back up straight in his wheelchair once the van was stopped and she had noticed a small abrasion/scratch on his knee. Nurse #1 stated she immediately completed an assessment which included checking for signs and symptoms of a fracture with no abnormalities noted other than a scratch and some bruising to his right knee which she treated with TAO and applied a dry dressing. She added Resident #70 complained of no pain and when asked what happened he confirmed what TD #1 had reported to her. Nurse #1 added when she provided care to Resident #70 on 05/18/21, he complained of pain and was given Tylenol. She added when she assessed his leg on 05/18/21, there were no signs of obvious fracture and the only injury noted was the scratch and bruising to his knee. On the morning of 05/19/21, Resident #70 complained of increased pain, she notified the NP and an order was obtained for an x-ray. Nurse #1 explained she didn't notify the NP on 05/17/21 because Resident #70 complained of no pain, did not hit his head and upon assessment there was no signs of a fracture. Nurse #1 stated Resident #70 never mentioned to her at any point the lap/chest belt was loose and he flew forward in the van hitting the console and if he had, she would have immediately notified the Physician or NP. The Nurse Practitioner (NP) progress note dated 05/19/21 read in part, Resident #70 seen for assessment of left leg pain. Per nursing staff, Resident #70 had an appointment on 05/17/21 and upon return to the facility, he slid out of the wheelchair in the facility transportation vehicle. Resident #70 reports he bent his left and right leg underneath the wheelchair at the time of his fall and since then has had increased pain in the left leg. The physical exam noted internal rotation of the left lower extremity and increased pain on palpation. Orders were given for: [MEDICATION(S)] (pain medication) 5/325 milligrams every 4 hours as needed for pain, topical antibiotic ointment for the left shin abrasion and transfer to the Emergency Department (ED) for treatment of left tibia-fibula fracture. During interviews on 08/04/21 at 11:30 AM and 3:42 PM, the NP stated she was notified the morning of 05/19/21 that Resident #70 had an accident while being transported in the facility van on 05/17/21 and his leg was injured and painful at which time, she gave orders for pain medication and to obtain an x-ray of his lower leg. The NP stated when she arrived at the facility on 05/19/21 and assessed Resident #70's leg, she noticed it was swollen with bruising to his knee but there were no obvious signs of a fracture such as deformity or protrusion. However, once the results of the x-ray were received it showed a definite fracture and orders were given to send Resident #70 to the ED for evaluation and treatment. The NP stated Nurse #1 should have notified her on 5/17/21 when the incident occurred instead of waiting 2 days and while it would not have changed the outcome, it did cause a delay in his treatment. The NP explained had she been informed of the incident on 05/17/21, she would have been able to identify the fracture sooner. During a telephone interview on 08/10/21 04:30 PM Nurse #2 confirmed she was assigned to provide care to Resident #70 during second shift on 05/17/21, 05/18/21 and 05/19/21. Nurse #2 stated when she reported to work the afternoon of 05/17/21, she was not told of the incident that occurred in the facility transport van and did not find out about the incident until she reported to work the afternoon of 05/18/21. Nurse #2 did not recall observing Resident #70's leg on 05/18/21 or of him complaining of any pain. She explained when he did voice pain, which was usually after therapy, he was provided pain medication that was effective. On 05/19/21 when she reported to work, he was in the process of being sent out to the hospital due to a confirmed leg fracture and when he returned from the hospital that evening, he had cast on his leg. Results of the mobile x-ray completed at the facility on 05/19/21 noted Resident #70 had a 2-view ankle x-ray which indicated in part, there is a mildly displaced fracture of the distal tibia and a non-displaced fracture of the distal fibula compatible with fractures of indeterminate (not exactly known) age in the appropriate clinical setting. Severe osteopenia (reduced bone mass) is noted. During a telephone interview on 08/05/21 at 3:00 PM, the Radiologist reviewed Resident #70's x-ray result and stated the tibia fracture looked acute (severe and sudden in onset) to him. He explained there was no healing callous (the bony healing tissue which forms around the ends of broken bone) observed on the x-ray which would have typically been noted on the x-ray 2 weeks after a fracture. The fibula fracture was a hairline fracture and hard to see. The Radiologist explained normally, a person would be in a lot of pain with this type of fracture but Resident #70 was not weight bearing. The Emergency Medical Service Transfer: Emergency Department to Floor Report dated 5/19/21 at 5:06 PM read in part, reason for visit: fall, leg pain, unspecified fracture of left tibia, initial encounter for closed fracture, unspecified fracture of shaft of left fibula, initial encounter for closed fracture. Pain assessment: patient is not reporting any pain. The hospital discharge after care notes dated 05/19/21 read in part, reason for visit - fall, leg pain. Discharge diagnoses were listed as closed left tibial fracture and fracture of left fibula. During a telephone interview on 08/06/21 at 9:26 AM the Medical Director (MD) did not recall being notified of the incident on 05/17/21 involving Resident #70 but stated the NP was notified and evaluated him on 05/19/21. The MD explained Resident #70's bones were very weak and brittle and simply sliding out of the wheelchair could cause his bones to break. During an interview on 08/04/21 at 9:07 AM, TD #2 stated he typically transported residents to their appointments in the morning and TD #1 took over in the afternoon. TD #2 explained when securing a resident in the facility transport van, he locked the brakes on the resident's wheelchair, secured the wheelchair in place using the 4-point securement floor straps, placed the lap/chest belt across the resident, and then shook the wheelchair side-to-side, which caused the straps to automatically tighten, to ensure the wheelchair was secure. TD #2 confirmed on the morning of 05/17/21, he transported and dropped off Resident #70 and NA #1 at his appointment with no incident. He added, TD #1 picked Resident #70 and NA #1 up later that afternoon to bring them back to the facility. During an interview, the Administrator recalled on 5/19/21, she was informed Resident #70 was complaining of increased pain after an accident in the facility transport van and an order was received from the NP for a 2-view x-ray. The Administrator immediately went to assess Resident #70 and described his legs as twisted slightly at baseline due to his diagnosis of [CONDITION(S)] disease. She recalled his left leg was warm and swollen and he complained of pain but displayed no obvious signs of fracture. She added, to be honest, I thought it was [CONDITION(S)]. She discussed the incident with TD #1 and NA #1 as well as Resident #70 whose details of the event continued to change. She added Resident #70 never stated he had flown forward from the wheelchair into the dashboard and had no injuries to support that statement. After it was determined he did sustain a fracture, she immediately started an investigation which identified the concern that Nurse #1 failed to notify the MD/NP of the incident on the day it occurred. In addition, she indicated they also concluded he was left sitting on the shower mesh mechanical lift sling when placed in his wheelchair with no cushion. She explained since the sling used was a slippery material, they felt if there had been a cushion, that she described as made with a rubbery type material, in the seat when he was placed in the wheelchair on the sling, then it wouldn't have been as slick making it less likely for him to slide out of the wheelchair. The Administrator stated a plan of action was developed on 05/19/21 to address the prompt notification of the physician and Responsible Party (RP) of a resident's change in condition and was presented to the Quality Assurance (QA) committee on 05/20/21. She explained the plan of action included: staff education that was provided to all licensed Nurses and Medication Aides related to notifying the physician and RP promptly of any change in condition; audits of clinical documentation and incident/accident reports to ensure notifications were completed timely; and monitoring systems put into place to ensure continued compliance that were still ongoing. The Administrator stated they never considered the possibility the chest/lap belt was not properly secured at the time of the incident since both TD #1 and NA #1 confirmed it was intact; therefore, the possibility Resident #70 was not secure at the time of the incident was not considered a factor when trying to determine a possible root cause. The Administrator confirmed they were unable to determine what actually occurred to cause Resident #70 to slip out of the wheelchair and stated she felt it was an unfortunate, freak accident. A telephone interview with a Representative of the manufacturer of the wheelchair safety securement system utilized by the facility was conducted on 08/06/21 at 3:36 PM. The Representative stated they recommended using the chest/lap belt when transporting a resident in the transport van by placing the lap belt underneath the arm rest and across the lap tightly to prevent someone from sliding out of the wheelchair. The Representative added if the lap/chest belt was properly applied and secured according to the manufacturer's instructions, then Resident #70 should not have been able to slide out of the wheelchair during transport. An observation of a shower mesh mechanical lift sling that was used to transfer Resident #70 was conducted with the Administrator on 08/04/21 at 4:29 PM. The base and sides of the sling were a slippery, mesh material with fabric straps on each end that attached to the mechanical lift when used for transfers. An observation of the facility transport van and follow-up interview was conducted on 08/05/21 with TD #1. Surveyor #1 was seated in the transport wheelchair used to transport Resident #70 to his appointment on 05/17/21. TD #1 locked the brakes of the wheelchair, attached the 4-floor securement hooks onto the wheelchair and checked to make sure the locking system was secure. TD #1 then attached the chest/lap belt and checked for securement. The wheelchair was placed in the middle just behind the driver and passenger seats. When the wheelchair was shaken side-to-side, the floor straps and locks remained secure. When leaning forward from a sitting position, the lap belt tightened while the chest/shoulder strap gave approximately 12 inches allowing the upper body to lean forward before tightening and preventing a fall out of the wheelchair. During the observation, TD #1 described Resident #70 was seated in the wheelchair leaning slightly toward the right side with his legs angled toward the left, in between the footrests of the wheelchair. TD #1 explained when Resident #70 slid out of the wheelchair during transport and she stopped the van, his right knee landed on the floor of the van and his lower left and right legs were on the floor underneath the left footrest of the wheelchair. She restated the lap/chest belt remained in a locked position but his lower body had slid down from under the lap belt allowing his knee to hit the floor while his bottom had remained resting on the edge of the seat. The Administrator and Regional Clinical Consultant were notified of Immediate Jeopardy on 08/06/21 at 2:06 PM. The facility provided the following Credible Allegation of Immediate Jeopardy Removal: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 5/17/2021 at approx. 11:30am, Resident #70 was being transported in the facility's van back to the facility following an appointment accompanied by Transport Driver #1 and Nurse Aide #1. During transport, Resident #70 informed Transport Driver #1 he was sliding out of his wheelchair. Transport Driver #1 immediately pulled the van over to the side of the road and both she and Nurse Aide #1 noted Resident #70 had slid down, but he was not completely out of his wheelchair. Transport Driver #1 reported that Resident #70 had his upper body (above the waist) was still in the wheelchair, being secured by the chest/lap belt. Per Transport Driver #1 Resident #70 right knee was on the floor of the van and his left leg was on the floor and underneath the footrest of the wheelchair. Transport Driver #1 and Nurse Aide #1 assisted Resident #70 back into wheelchair, making sure that his seat/lap belt and wheelchair were all secure and continued back to the facility. At approx. 12:30, Transport Driver #1 arrived back to the facility with Resident #70. Transport Driver #1 notified Nurse #1 of Resident #70 sliding out of the wheelchair. In a nursing note by Nurse #1 on 5/17/2021 at 4:02pm read in part that Resident #70 returned from appointment with no new orders. Transport Driver #1 reported that Resident #70 slid out of wheelchair and had bruises to his leg. Resident #70 confirmed incident. Bruises on left leg cleaned with wound cleanser and covered with TAO and dry dressing, treatment provided by Nurse #1. Nurse #1 noted resident denied pain. Responsible Party contacted, no answer, nurse monitoring. Incident report, fall and pain assessment completed by Nurse #1. Nurse #1 reported that she completed an assessment which included checking for sign/symptoms of a fracture with no abnormalities noted other than the scratch and bruising to his left leg in which she treated with the TAO and a dressing. On 5/18/2021 at 2:24 AM Nurse #2 noted resident status post fall with bruise to left leg with no complaints of pain and no acute distress. On 5/18/2021 Nurse #1 reported during her shift (1st) that resident #70 complained of pain to left leg and was given Tylenol that she reported was effective, she also reported she assessed Resident #70 leg and there were no signs of obvious fracture and the only injury noted was the scratch and bruise to his left leg. On 5/19/2021 at 9:44 am Nurse #2 noted bruising to left leg persist no complaints of pain or discomfort. On 5/19/2021 at 11:16am, Resident #70 complained of pain in the left ankle. Nurse #1 notified Nurse Practitioner #1 (NP). NP gave order for STAT two view x-ray to left ankle. On 5/19/2021 at approx. 12:30pm, Transport Driver #1 provided a return demonstration of how Resident #70 was secured in the wheelchair in the van to Administer and Regional Director of Operations. Transport Driver #1 was able to demonstrate proper use of the four-point wheelchair restraints and chest/lap belt to secure resident. During interview with Transport Driver #1 it was noted that Resident #70 did not have a cushion in his chair and the shower mesh sling had been left under the resident during transport. On 5/19/2021 at 2:02pm x-ray findings showed mildly displaced oblique fracture of the distal diaphysis of the tibia and nondisplaced fracture of the distal fibula. Severe osteopenia noted. Nurse Practitioner #1 gave order to send resident to emergency room for evaluation and treatment. 5/19/2021 at approx. 11:00pm Resident #70 returned to the facility with discharge diagnosis of closed left tibial fracture and fracture of the left fibula. Resident #70 is to follow up with CMC Orthopedics [NAME] within one week for reevaluation of leg fracture. Resident #70 was seen at CMC Orthopedics [NAME] on 5/24/2021 to continue with soft cast/splint. 8/2/2021 CMC orthopedic instructions to continue Fracture Brace every day to left lower extremity and to follow up in 3-4 months with new x-rays before appointment, appointment may be virtual. The facility failed to ensure proper positioning and securement of Resident #70 while in the transport van to prevent Resident #70 from sliding/falling out of wheelchair during transport. All residents that are transported have the potential to be affected when policies and procedures for proper positioning are not followed. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: 100% of all drivers' education records were audited on 5/20/2021 and reaudited on 8/6/2021 by the facility Administrator and/or Director of Nursing, to ensure each driver receives necessary education to drive the van safely. All drivers noted to have necessary training and qualification to drive the facility Van to include what to do in-case of an emergency. 100% of residents who has an incident or accident for the last 30 days starting on 4/17/2021 through 5/17/2021 were audited by the facility Director of Nursing on 5/20/2021 to identify any other resident with an incident or accident who was moved without a licensed nurse's assessment and to ensure proper MD and RP notification was completed. No other resident identified to be moved before licensed nurse assessed the resident. Findings of this audit is documented on the incident log audit maintained in the facility compliance binder. 100% of residents who had an incident or accident for the last 14 days starting on 7/23/2021 through 8/6/2021 were audited by the Regional Clinical Consultant on 8/6/2021 to identify any other resident with an incident or accident who was moved without a licensed nurse's assessment and to ensure proper MD and RP notification was completed. No other resident identified to be moved before licensed nurse assessed the resident. Findings of this audit is documented on the incident log audit maintained in the facility compliance binder. Audit was conducted by Nurse Management to include Director of Nursing, Assistant Director of Nursing, and Unit Managers of all residents that require a mechanical lift transfer to ensure lift slings is removed when transfer is complete. Initial Audit completed on 5/20/2021 and re-audit conducted on 8/6/2021. No issues noted. Regional Plant Operations Manager will audit/inspect the Q-straint system to include floor securements, chest/ shoulder and lap belt for proper engagement, securement, and function on 8/9/2021. Any identified issues will be corrected. Effective 8/6/2021 all non-licensed employees will not move any resident involved in an incident or accident, to include the incidents happened in the facility van when a resident experience any fall until the resident is assessed by the trained personnel. The Facility staff will ensure patient safety is maintained while waiting for help to arrive effective 8/6/2021. Executive Director, and/or Director of Nursing conducted initial education on 5/19/2021-5/20/2021 and re-education began on 8/6/2021 for current staff members to include contract staff. This education included the importance of ensuring resident is not moved from the floor when resident incident or accident occurred until proper assessments are completed by the appropriate, trained personnel (medical provider, licensed nurse and/or emergency medical transport and or paramedic). This education will be completed by 8/9/2021, any staff member not educated by 8/9/2021 will not be allowed to work until educated on this requirement. This education will be added on new hires orientation education for all new facility staffs. This education will also be provided annually for all facility staff to include drivers. In-service form stated The resident should be kept safe in the location observed until help arrived. If a resident fell in an area that put resident at further risk for injuries, extreme precautions must be taken to ensure resident's injuries are not exacerbated, should the resident be moved. Ex [TRUNCATED]

Based on observations, record reviews, resident, staff and Medical Doctor (MD) interviews, the facility failed to manage and treat complaints of pain for 1 of 1 resident (Residents #410) reviewed for pain. The facility failed to manage Resident #410's pain during surgical wound dressing changes which resulted in the resident experiencing severe pain. The facility also failed to administer pain medication to Resident #410 during dressing changes as per the physician order. The findings included: Resident #410 was admitted to the facility from a hospital on 07/20/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated 07/20/21 revealed Resident #410 had a surgical wound to his mid buttocks. The care plan goal was for Resident # 410's wound to heal and return home. Treatments included the wound to be packed and a fresh dressing applied two times a day. Review of Resident #410's admission Minimum Data Set, dated dated [DATE] revealed Resident #410 was cognitively intact and had a surgical wound. The MD's order dated 07/20/21 revealed the following order for wound care: Dakin's 0.25% solution (a solution used to kill germs and prevent germ growth in wounds) soaked gauzes were to be applied to the buttocks wound and covered with dry gauze and abdominal pads (which are non-adherent) secured with tape twice a day. Resident #410's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a NP progress note dated 07/23/21 revealed Reports his pain is increasing daily with dressing changes and rates his pain a 10/10. He reports with the medication his dressing changes puts his pain at 5-6/10. In a NP progress note dated 7/27/21, the NP documented that Resident #410 has been started on [MEDICATION(S)] 4 mg 30 minutes prior to dressing change and his pain as been controlled. She documented per nursing resident did not exhibit increased pain response with wound care prior to his initiation on [MEDICATION(S)] for his pain and he tolerated dressing change without [MEDICATION(S)] dose. She noted she would discontinue the [MEDICATION(S)]. Record review of progress note dated 08/02/21 written by the physician stated, Patient states the pain medication he is receiving inadequate to control his discomfort, stated he was receiving [MEDICATION(S)] 2 mg prior to dressing change which is a decrease in the dosage first ordered and requesting to have medication returned to 4 mg [MEDICATION(S)] before dressing change. He documented he will reinitiate his pain medication. Review of Resident #410's pain medication orders revealed the following: 7/20/21 - Acetaminophen 325 mg tablet give one tablet by mouth every six hours for pain 7/20/21 - [MEDICATION(S)] - Acetaminophen 5-325 mg, one tab every 6 hours for moderate pain as needed. 7/23/21 - [MEDICATION(S)] 4 mg tablet take 1 tablet daily before dressing changes. 7/24/21 - Discontinued [MEDICATION(S)] - Acetaminophen 5-325 mg, one tab every 6 hours for moderate pain as needed. 07/26/21 - [MEDICATION(S)] - Acetaminophen 5-325 mg take one tablet by mouth every 6 hours as needed for pain 7/27/21 - Discontinue [MEDICATION(S)] 4 mg by Nurse Practioner (NP). 8/02/21 - [MEDICATION(S)] 4 mg tablet give one tablet by mouth 30 minutes before dressing changes for pain 8/03/21 - [MEDICATION(S)] 4 mg tablet give one tablet for one time by mouth before dressing change. Do not give any more for today 8/3/2021. 8/05/21 - Discontinued Acetaminophen 325 mg tablet give one tablet by mouth every six hours for pain 08/05/21 - Acetaminophen 325 mg tablet take 1 tablet by mouth every 6 hours for pain (re-ordered) 8/06/21 - [MEDICATION(S)] 4 mg tablet take one tablet by mouth one time for dressing change 8/06/21 - Discontinue [MEDICATION(S)] 4 mg. 8/06/21 - [MEDICATION(S)] 4 mg tablet take one tablet by mouth one time for dressing change - (second order for this med on 8/6/21). 8/06/21 - [MEDICATION(S)] discontinued. A. 7/23/21 - 7/26/21: Per the Treatment Administration Record (TAR), Resident #410 had 8 dressing changes and per the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] times with dressing changes. B. 7/27/21 - 8/1/21 - Per the TAR Resident #410 had 12 dressing changes and per MD orders no Diaudid ordered for dressing changes. [MEDICATION(S)] - Acetaminophen 5-325 mg was available for pain. C. 8/2/21 - 8/9/21 - Per the TAR Resident #410 had 16 dressing changes and per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] medicated 8 times with dressing changes. An observation of wound care on Resident #410 on 08/3/21 at 11:30 AM by a Wound Nurse # 2 revealed that resident #410 was medicated with [MEDICATION(S)] 4 milligrams (mg) at 10:46 AM. The resident flinched in pain a few times while the packing was being replaced but said he was okay to continue. He stated the [MEDICATION(S)] made all the difference. He stated the wound felt so much better when the dressing was fresh, but towards the 10-12 hour mark the dressing dried out and started to hurt. In an interview on 08/01/21 at 3:15 PM with Resident #410 he stated the packing and dressing change of his wound was very painful. He stated he saw the NP today and told her the current medication of [MEDICATION(S)] Acetaminophen 5-325 mg one tablet every 6 hours as needed was not strong enough for his pain during wound care. He stated on 07/23/21 he was ordered 4 mg of [MEDICATION(S)] (an opioid pain medication), one tablet before wound care and it made a significant difference in his pain. Resident # 410 stated his pain level without the [MEDICATION(S)] during wound care was 9-10 out of 10. He stated he would clench his fists; his body would be very tense, and he would be tearful. He stated his pain level during wound care with [MEDICATION(S)] was 5-6 out of 10 and manageable. He stated things were going alright until the NP discontinued the [MEDICATION(S)] on 07/27/21. In an interview with Resident #410's MD on 08/02/21 at 8:50 AM revealed he was not aware Resident #410 had any concerns with his dressings changes. He stated he was unaware the order for [MEDICATION(S)] before wound care had been discontinued, and that Resident #410 had complained about severe pain with wound care without the medication. The physician stated he would talk with Resident #410 and the NP. In an interview on 08/03/21 at 10:16 AM with the NP revealed that Wound Nurse #1 told her she forgot to give Resident #410 his [MEDICATION(S)] before his wound care on 07/26/21 and she felt he tolerated the dressing change well without pain medication. The NP stated she then decided to discontinue the [MEDICATION(S)]. In an interview with Resident #410 on 08/04/21at 9:40 AM he stated he asked the NP why he wasn't getting [MEDICATION(S)] for dressing changes. She stated that Wound Nurse #1 had told her he was not having pain during dressing changes. Resident #410 stated he told her he was surprised by that because when his dressing changes were done without [MEDICATION(S)] his pain level was nine-ten out of ten, and with [MEDICATION(S)] his pain was a five-six out of 10 and manageable. He stated every day after the [MEDICATION(S)] was discontinued he told every wound nurse how much pain he was in during dressing changes. On 08/04/21 at 12:53 PM a phone interview was conducted with Wound Nurse #1 who stated initially Resident #410 did not mention pain with his wound care, but on 07/26/21 halfway through the wound care he told her he needed the [MEDICATION(S)] before he got his dressing changed. She stated she did not know anything about that order. Resident #410 told Wound Nurse #1 the order for [MEDICATION(S)] was written on 7/23/21. She stated she asked another nurse about the order, she didn't know her name, and the nurse pulled up the order in the computer so Wound Nurse #1 could verify. Wound Nurse #1 stated she discussed the order with the NP and told the NP he exhibited no signs of pain during wound care, and since his admission she had seen him up walking, sitting outside and smoking so he seemed to be fine An interview conducted on 08/05/21 at 2:10 PM with the Administrator revealed it was her expectation for physician pain medication orders to be followed as written. She stated she had seen the wound and knew it was bad. In a telephone interview with Nurse #3 on 08/06/21 at 06:06 PM she stated she performed wound care on several occasions and the wound was massive, so wide and deep. The first day she changed the wound the [MEDICATION(S)] had not been ordered and he experienced a lot of pain. Once the [MEDICATION(S)] was ordered and she could pre-medicate him she saw a big difference with his pain being decreased. She stated the dressing change was a very painful procedure and those nerve endings were not dead.

Based on record review and resident, staff, and the responding Police Officer interviews, the facility staff failed to report a resident kept a large sum of money on his person which put him at high risk for abuse, exploitation, and misappropriation and failed to prevent misappropriation of resident property when the money was removed from his pant pocket and stolen by an individual for 1 of 5 residents reviewed for abuse (Resident #98). The findings included: Resident #98 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #98 was listed as his own Responsible Party on the face sheet of his medical record and the first Power of Attorney (POA) listed on his advance directive. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #98 as being cognitively intact. Assistance needed for activities of daily living was assessed as requiring total assistance bed mobility, transfers, eating, and toilet use. There was no upper extremity range of motion impairment and impairment on both side of the lower extremities. Review of the 24-hour report revealed on 6/6/21 at 4:45 PM the facility became aware Resident #98 reported his money was stolen. The Police Department was notified, and an investigation started. Resident #98 was interviewed on 8/2/21 at 8:51 AM. Resident #98 revealed his named second POA had brought $9000.00 in cash to the facility upon his request. Resident #98 explained he was expecting to move out of the facility and after paying rent on a house he had $7200.00 left. Resident #98 kept the money in a double knotted sock. During the day the sock stayed in his pant pocket and at bedtime he asked Nurse Aide (NA) staff to put the sock in the pillowcase of the pillow he slept on. Resident #98 stated he didn't tell the Administrator about keeping a large amount of money because he preferred to keep his money close to him. Resident #98 explained the money was stolen from him on 6/6/21 by a male dressed in black scrubs who claimed he worked for the nursing agency the facility used. Resident #98 stated the male was able to locate him in the smoking area and appeared to know he had money in his pant pocket and removed the sock from his pocket then left the facility. Resident #98 revealed he identified the suspect on NA #4's social media. The male was somehow related to NA #4 and NA #5 and arrested by the police. Resident #98 provided the name of a resident who witnessed the theft and of NA staff who had seen or who he thought knew about the money in the sock. Resident #98 stated he experienced post-traumatic stress from the incident and didn't feel safe in the building and felt Administration didn't care and hadn't done anything about the incident. An interview was conducted on 8/05/21 at 11:33 AM with Nurse #12. Nurse #12 was the designated receptionist on 6/6/21 when a male she didn't recognize entered from the front door. She buzzed him in, and he told her he was from agency and gave his name. Nurse #12 checked the schedule kept at the front desk stating his name wasn't on it and that was not unusual, and the schedule frequently changed due to call outs. The male was wearing scrubs and no badge. The male said he was working on the south unit, so she gave him directions and he proceed that way. When the male came back, he was pushing the door and said he needed to go out to his car. She buzzed the door open for him and he exited the facility to the parking lot. Resident #98 was coming up the hallway saying something, but Nurse #12 couldn't hear what until he got to the front desk and stated that guy robbed me. The police were called and she thought Resident #98 told her it was around $7000.00 that was stolen. Nurse #12 stated she wasn't aware Resident #98 had a large amount of money on his person. Now agency staff must wear a badge and provide their ID and those were scanned and kept in a log book at the front desk along with the schedule to verify they are agency assigned to work. The person at front desk makes copies of agency staff IDs and dates the copy and places in the logbook. Review of the progress note written by the Social Worker on 6/18/21 revealed after meeting with his caseworker Resident #98 requested to receive psychotherapy services and an order was requested. A psychotherapy note dated 7/29/21 revealed Resident #98 reported he didn't want to participate in psychotherapy. The note read in part, today is his 3rd week in a row he has declined psychotherapy and was assessed if he wanted to continue services or would like to discharge. He reports doing well and wants to discharge from psychotherapy. An interview was conducted with the person listed as the second POA on 8/06/21 at 11:57 AM. The POA confirmed she brought $10,000.00 in cash and gave the money to Resident #98. The POA didn't recall the exact date the money was brought to the facility and explained Resident #98 wanted the money because he had expected to be discharged , so she brought the money to the facility. The POA didn't tell anyone about bringing the money to the facility. After the robbery Resident #98 told the POA he was robbed approximately 20 to 30 minutes after asking NA #4 to put the sock of money in his pant pocket. An interview was conducted on 8/10/21 at 9:45 AM with NA #2. NA #2 previously worked 2nd shift at the facility and had provided care to Resident #98 but wasn't there the day of the robbery. NA #2 revealed she counted the money when it was first brought to the facility and stated there was $9000.00 in cash. On the day NA #2 counted the money she placed the stack of money in plastic bag and put the bag in a knotted sock then in the pocket of Resident #98's pants. Afterwards when NA #2 assisted Resident #98 out of bed she would remove the sock from his pillowcase and place the money in his pant pocket. NA #2 didn't share with anyone else Resident #98 had $9000.00 in cash and stated, I told no one. NA #2 revealed there were 2 other NA staff who also knew about Resident #98's money but couldn't recall their names. NA #2 explained she didn't tell anyone about the money and Resident #98 was able to make his own decisions and she did not recall when it was brought to the facility or when she counted it. An interview was conducted with NA #4 on 8/10/21 at 4:34 PM. NA #4 revealed she and NA #5 (a family member) both worked for the staffing agency the facility used and 6/6/21 was her second day at the facility and first day caring for Resident #98. NA #4 explained on 6/6/21 around lunch time she and NA #5 used a mechanical lift to provide total assistance getting Resident #98 out of bed. Resident #98 asked NA #4 to reach under his pillow for a sock and place it inside his pant pocket. NA #4 stated she could tell there was something in the sock but couldn't see what and Resident #98 didn't tell her. NA #4 revealed Resident #98 was fed lunch by NA #5 who needed total assistance with eating and couldn't feed himself. NA #4 revealed she had not heard about any money until after the robbery and she repeated several times others knew about the money. Multiple attempts to interview NA #5 were unsuccessful. An interview was conducted on 8/09/21 at 4:31 PM with NA #11. NA #11 revealed Resident #98 told her he had $7000.00 before the incident happened and that he kept in a sock he tied in a knot. NA #11 revealed she didn't see the money but did see the sock and stated she could tell it was a large sum of money by the shape and described it looked like a big stack of money. Resident #98 would have NA #11 put the sock of money in his nightstand drawer which he had a key to lock. NA #11 would lock the drawer and put the key in container kept on top of the nightstand. When NA #11 would get Resident #98 out of bed he asked her to get his money out of the locked drawer and put it in his pocket. NA #11 revealed she didn't question the fact Resident #98 kept a large sum of money in his room and on his person stating he was of sound mind. An interview was conducted on 8/10/21 at 5:13 PM with NA #3. NA #3 revealed she had provided care for Resident #98 but wasn't told about the money. When NA #3 put Resident #98 to bed, he asked her to remove the sock from his pant pocket and place it in the pillowcase of the pillow behind his head. NA #3 revealed the sock appeared thick and she could tell it was money by the way it felt and by how protective and close Resident #98 kept the sock to his person. NA #3 revealed she started seeing the sock sometime in May but was unsure of exactly when and stated he didn't have it long. NA #3 explained when Resident #98's plans to discharge from the facility changed that was when she recalled seeing the sock. NA #3 didn't discuss this with anyone at or outside the facility. An interview was conducted on 8/12/21 at 1:42 PM with NA #6. NA #6 revealed she had seen Resident #98's money, which appeared to be a lot, but didn't know how much cash there actually was. NA #6 described Resident #98 had several stacks of money separated and banded together that were kept in a knotted sock. NA #6 explained at night whoever put Resident #98 to bed would place the sock in his pillowcase and whoever got him up would put the sock in his pant pocket. NA #6 stated she should have told someone about seeing that much money on a resident but felt like the Administrator or a Supervisor knew because Resident #98 was ready to leave the facility and in process of getting his own apartment. The Police Officer (PO) who responded to the robbery was interviewed on 8/11/21 at 3:29 PM. The PO revealed the suspect was able to gain access to Resident #98 after being let in the facility by giving a false name and stating he worked for the nursing agency used by the facility. Resident #98 identified the suspect on NA #4's social media who was also related to NA #4 and NA #5. The suspect was brought in for an ID line up, Resident #98 identified him as the perpetrator, and an arrest was made. An interview was conducted on 8/03/21 at 1:17 PM with the Administrator. The Administrator revealed NA #4 and NA #5 both worked for the agency company used by the facility and had worked the day of incident. The Administrator was unable to get an interview from either one. NA #4 called the facility on 6/7/21 and began screaming at the Administrator stating she and NA #5 had not stolen any money. The Administrator called the agency company and requested neither NA #4 nor NA #5 return to the facility. A follow up interview was conducted on 8/11/21 at 11:47 AM with the Administrator. The Administrator explained Resident #98 felt like someone from the facility had tipped off the robber but was unsure who. After her 5- day investigation Resident #98 did share with her he thought NA#4 and NA #5 had tipped someone off because they were the 2 newest staff. The Administrator explained Resident #98 shared with her that other staff members at the facility were aware he had money, but he didn't think they knew how much and didn't name anyone who had counted or seen his money. After the incident, employees were trained, and her in-service included educating staff to report to her or the Social Worker (SW) when they see a resident with a lot of money. Either her or the SW would meet with the resident and ask if they would like to put the money in the business office safe or lock in their nightstand and also educated not to show the money to others if they chose not to put in the safe. An interview was conducted on 8/12/21 at 10:19 AM with the Administrator. The Administrator revealed the staff she interviewed thought Resident #98 had money but didn't know how much and no one ever reported anything to her. The Administrator stated if NA #2 counted $9000.00 in cash for Resident #98 she hoped NA #2 would report that to her even though Resident #98 was able to make his own decisions. The Administrator stated if any of the NA staff had informed her Resident #98 had a large amount of money he was keeping at the facility, she would've told him the money needed to be locked up in the safe. In addition, if Resident #98's second POA would've informed her she brought a large sum of money to the facility, she would've told the POA to take it back. The Administrator confirmed when NA#2 counted Resident #98's money and allowed him to keep a large sum of money on his person, he was put at risk for misappropriation of property.

Based on staff, nurse practitioner and physician interviews, and record review, the facility failed to identify hematuria (blood in the urine) as a symptom of an indwelling urinary catheter complication and failed to respond and monitor symptoms of urinary retention for 1 of 3 sampled residents who used an indwelling urinary catheter (Resident #1). This failure resulted in an emergency transfer for Resident #1 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy began on 04/17/2021 when facility staff did not identify Resident #1's hematuria as a symptom of an indwelling urinary catheter complication and did not respond or monitor symptoms of urinary retention. Staff assigned to Resident #1 did not identify hematuria as an acute condition and immediately contact the physician for further guidance. Resident #1 required an emergency transfer to the hospital for gross bleeding from the indwelling urinary catheter site. The Immediate Jeopardy was removed on 04/28/2021 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission medication orders dated 01/22/2021 directed Resident #1 to receive [MEDICATION(S)] 5 milligrams twice daily. (According to the pharmaceutical manufacturer, [MEDICATION(S)] is an anticoagulant medication to prevent blood clots.) Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented an assessment of severely impaired cognition. The MDS indicated Resident #1 used an indwelling urinary catheter and daily administration of an anticoagulant. The care plan dated 02/09/2021 for Resident #1 included interventions to be free of infection and discomfort related to catheter placement. Interventions included assessment of the color, clarity and character of urine and assessment of symptoms of urinary tract infection. A nurse practitioner (NP) note dated 02/03/2021 documented Resident #1 experienced acute urinary retention. Resident #1's abdomen was distended with no urinary output. The NP obtained 1500 cubic centimeters (cc) of bloody urine when the indwelling catheter was replaced. The NP ordered scheduled irrigation of the indwelling urinary catheter to prevent clot formation. On 02/08/2021, the NP documented Resident #1's urine culture and sensitivity result indicated a urinary tract infection (UTI) which required antibiotic therapy. On 02/10/2021, the NP documented Resident #1's previous hematuria with clots and catheter leakage was resolved. Resident #1 was hospitalized from 03/10/2021 to 03/26/2021 and the discharge summary dated 03/26/2021 indicated Resident #1's indwelling urinary catheter was replaced due to bilateral hydronephrosis which caused urinary retention secondary to a urinary tract infection. (Hydronephrosis occurs when a kidney has an excess of fluid due to a backup of urine.) The discharge summary did not contain orders for scheduled irrigation of the indwelling urinary catheter. Readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP assessed Resident #1 on 03/29/2021 and documented Resident #1's indwelling urinary catheter contained clear, yellow urine. Resident #1 had no bladder distention upon palpation. The NP documented nursing staff were to monitor bladder distention and episodes of hematuria. On 04/02/2021 and 04/05/2021, the NP documented Resident #1's indwelling urinary catheter contained clear, yellow urine. Resident #1 had no bladder distention upon palpation. A physician's note dated 04/08/2021 documented Resident #1's indwelling urinary catheter contained clear, yellow urine. Resident #1 had no bladder distention upon palpation. The NP documented on 04/09/2021 and 04/12/2021 that Resident #1's indwelling urinary catheter contained clear, yellow urine. Resident #1 had no bladder distention upon palpation. A nursing note, written by Nurse #1, dated Saturday 04/17/2021 at 6:55 PM documented Resident #1's urine contained dark red blood. The nurse wrote Resident #1 was verbal with increased sleepiness and placed Resident #1's name in the medical doctor book to be seen Monday, 04/19/2021. There was no description of the amount of urine or vital sign measurement. Interview with NA #1 on 04/26/2021 at 10:50 AM revealed Resident #1 did not want to get out of bed on 04/17/2021 and slept most of the day. NA #1 explained Resident #1 usually got out of bed and liked to talk. NA #1 reported Resident #1's indwelling urinary catheter bag contained approximately 800 cc. of blood tinged urine when it was emptied at the end of the shift at 3:00 PM. NA #1 reported the amount of urine was Resident #1's usual amount. NA #1 reported the color of urine to Nurse #1 who was aware of the discolored urine. A telephone interview was conducted on 04/26/2021 at 12:48 PM with Nurse #1. Nurse #1 reported she worked from 7:00 AM to 7:00 PM every weekend and cared for Resident #1 on 04/17/2021. Nurse #1 reported she fed Resident #1 the breakfast meal on 04/17/2021 and several hours later observed dark red urine in the catheter bag. Nurse #1 estimated the amount was 500 cc. Nurse #1 explained Resident #1 slept more than usual but did not complain of pain. Resident #1's abdomen was not distended. Nurse #1 explained she placed Resident #1's name and concern of hematuria on the list to be seen on Monday (04/19/2021) by the NP. Nurse #1 did not consider the hematuria urgent since Resident #1 experienced hematuria in the past. Nurse #1 reported the hematuria to Nurse #2 who came on duty at 7:00 PM. Telephone interview with Nurse #2 on 04/26/2021 at 12:20 PM revealed she was not aware of and did not observe Resident #1's hematuria on 04/17/2021 between 7:00 PM and 11:00 PM. Nurse #2 documented administration of [MEDICATION(S)] 5 mg. at 8:00 PM. During an interview with NA #2 on 04/26/2021 at 3:25 PM, NA #2 reported she cared for Resident #1 from 3:00 PM to 11:00 PM on 04/17/2021. NA #2 reported she did not recall the character, color or amount of Resident #1's urine when she emptied the bag at the end of the shift at 11:00 PM. A nursing note, written by Nurse #3, dated 04/18/2021 at 6:29 AM documented Resident #1 continued with hematuria with no complaints of discomfort during the 11:00 PM to 7:00 AM shift. Telephone interview with NA #3 on 04/26/2021 at 2:45 PM revealed she cared for Resident #1 from 11:00 PM on 04/17/2021 to 7:00 AM on 04/18/2021. NA #3 reported Resident #1's catheter bag contained a small amount of dark red urine when she emptied it at the end of her shift. NA #3 reported the discolored urine and small amount to Nurse #3. A telephone interview was conducted with Nurse #3 on 04/26/2021 at 6:10 PM. Nurse #3 explained she was not aware of Resident #1's hematuria until informed by NA #3 between 6:30 AM and 7:00 AM on 04/18/2021. Nurse #3 looked at Resident #1's clinical record and noted Nurse #1 documented hematuria on 04/17/2021. Nurse #3 did not recall NA #3 report of the small amount of urine. Nurse #3 informed the oncoming nurse, Nurse #1, of the continued hematuria. A nursing note, written by Nurse #1, dated 04/18/2021 at 10:44 AM documented Resident #1's hematuria continued with blood coming out of the catheter insertion site. Blood covered Resident #1's groin, inner thighs and pubic area. Resident #1's blood pressure measured 137/93 mm/Hg., heart rate of 103, respiratory rate of 18 and temperature measurement of 97.7 degrees Fahrenheit. Resident #1 received an emergency transfer to the hospital. During a telephone interview on 04/26/2021 at 12:48 PM with Nurse #1, Nurse #1 reported she attempted to feed Resident #1 the breakfast meal on 04/18/2021 but he accepted only a few bites of food and sips of a carbonated beverage. Nurse #1 held Resident #1's medications due to lethargy. Nurse #1 reported there was no urine in Resident #1's urinary catheter bag when she fed him breakfast at approximately 8:30 AM. When she returned approximately one hour later to check on Resident #1, his top sheet contained blood. Upon further examination, Nurse #1 observed blood covered Resident #1's groin and thighs with blood coming out of the penis. Nurse #1 reported Resident #1's abdomen was distended and hard with no urinary output. Nurse #1 stated she immediately transferred Resident #1 to the hospital at approximately 10:30 AM on 04/18/2021. Resident #1's emergency room evaluation dated 04/18/2021 documented Resident #1's indwelling urinary catheter was replaced which resulted in immediate 2700 cc of bloody output and subsequently 1 liter of dark yellow colored urine. The hospital physician documented post renal acute kidney injury with [CONDITION(S)], suspected secondary clot with catheter and [CONDITION(S)] secondary to fluid overload from urinary obstruction. Resident #1 was admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the NP on 04/26/2021 at 11:14 AM revealed staff should have notified the on-call physician when Resident #1's hematuria occurred to obtain orders for irrigation and probable replacement of the urinary catheter. The NP explained Resident #1 required monitoring for symptoms of infection, recurrence of blood clots and complications of urinary catheter use. Telephone interview with Resident #1's physician on 04/26/2021 at 4:46 PM revealed Resident #1 would have received catheter irrigation and immediate discontinuance of the anti-coagulant had staff contacted the on-call physician service when the hematuria occurred. The physician explained the onset of hematuria was a serious concern and required response. Interview with the Director of Nursing (DON) on 04/26/2021 at 4:55 PM revealed staff should have contacted Resident #1's physician on-call when the hematuria first occurred. The DON reported staff should recognize hematuria as a symptom of a urinary catheter complication and monitor symptoms of urinary retention. The DON explained Resident #1 was at risk for bleeding due to anti-coagulant use. The Administrator was notified of Immediate Jeopardy on 04/27/2021 at 1:55 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Nurse #1 noted Resident #1 on 4/17/2021 urine contained dark red blood. Nurse #1 failed to immediately notify MD of hematuria as she felt it was non-urgent, related to Resident #1 history of hematuria. Subsequently, Resident #1 hematuria was communicated via MD communication book. Nurse that worked 7pm to 11pm documented that Resident #1 received 8pm dose of [MEDICATION(S)] (Anticoagulation) as Nurse reported that she was unaware of the hematuria. Night shift nurse on 4/17/2021 documented in nursing note that Resident #1 hematuria continued, MD was not notified. During interview Night shift nurse stated that she did not recall any mention of small amount of urine. On 4/18/2021, Nurse #1 documented that Resident#1 did not have urine in the catheter bag when she fed him that morning, MD was not immediately contacted. Nurse #1 checked back an hour later to find no urine output and abdomen distended and hard. Nurse #1 documented in nursing note that hematuria continued with blood coming out of the urinary catheter insertion site. Blood covered Resident #1 groin, inner thighs, and pubic area. Resident was sent out to ER for evaluation. Resident #1's emergency room evaluation dated 04/18/2021 documented Resident #1's urinary catheter was replaced which resulted in immediate 2700 cubic centimeters of bloody output and subsequently 1 Liter of dark yellow colored urine. The physician ordered Resident #1's [MEDICATION(S)] to be held. The hospital physician documented post renal acute kidney injury with [CONDITION(S)], suspected secondary clot with catheter and [CONDITION(S)] secondary to fluid overload from urinary obstruction. Resident #1 was admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 has not returned to the facility. Facility did not identify hematuria as a symptom of an indwelling urinary catheter complication and did not respond nor monitor symptoms of urinary retention. Additionally, Resident #1 was receiving anticoagulation therapy which placed him at a higher risk of bleeding. Staff assigned to Resident #1 did not identify hematuria as an acute condition and immediately contact MD for further guidance. All residents with Indwelling Catheters have the potential to be affected by the deficient practice. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: An audit of the past 14 days of nursing notes completed 4/27/2021 was reviewed by the Executive Director, Director of Nursing, Assistant Director of Nursing, and Unit Coordinators to identify any residents with documented signs and symptoms of urinary retention or urinary tract infection. No issues identified. Additionally, an assessment of all Residents with Indwelling Catheters was completed on 4/27/2021 by the Director of Nursing to assess for any signs and symptoms of urinary retention, catheter complications, or urinary tract infection. Assessment included observation of catheter, urine color, clarity and output, abdominal inspection/palpation. No issues identified. Director of Nursing reviewed residents with Indwelling catheters on 4/26/2021 to ensure that each had an appropriate care plan to assess for color, clarity, character of urine and to assess for urinary tract infection and blockages. Care guides reviewed to ensure accuracy. No concerns noted. Beginning 4/27/2021, All nursing staff to include Licensed Nurses, Certified Nurse Aides, and Nurse Aids in Training will be re-educated by the Assistant Director of Nursing on the monitoring and reporting of residents with signs and symptoms of urinary retention and urinary tract infections. To include immediate notification of hematuria, decrease in urine output, pain, abdominal distention, pain with abdominal palpation, odor, urgency, frequency, catheter dislodgment, and or blockage. These changes are not to be communicated via communication book. The education will be communicated verbally and telephonically by the Executive Director, Director of Nursing and Assistant Director of Nursing/Staff Development coordinator. Written education will be available for review prior to the staff member working their assigned shift. Assistant Director of Nursing will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Beginning 4/27/2021, All Licensed Nurses to be educated on Change In Condition Notifications, Signs and Symptoms and when to report to MD. Documentation for residents with indwelling urinary catheters to include color, clarity, output, consistency of urine and documentation of site for redness, swelling, bleeding, warmth, discharge, or pain by the Assistant Director of Nursing. As well, all Licensed Nurses to be re-educated on their responsibility regarding shift-to-shift reporting utilizing 24-hour report sheets and giving accurate, clear, timely report to on coming shifts by the Assistant Director of Nursing. Additionally, all Licensed Nurses to be re-educated on adverse side effects to Anticoagulants which include hematuria, monitoring/assessing for adverse reaction and the immediate notification to MD. The education will be communicated verbally and telephonically by the Executive Director, Director of Nursing and Assistant Director of Nursing/Staff Development coordinator. Written education will be available for review prior to the staff member working their assigned shift. Assistant Director of Nursing will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Effective 4/27/2021 education for management of residents with urinary catheters, including monitoring for complication and how to respond will be included in general orientation by the Staff Development Coordinator for newly hired Licensed Nurses and Certified Nursing Assistants. Effective 4/27/2021 Nursing Management to include Charge Nurse, Unit Coordinators, Director and Assistant Director of Nursing will review 24-hour report sheets and previous day nurses notes to identify any change in condition for appropriate follow up and notification to MD review will be completed daily. Administrator educated the Nursing Management team to include Charge Nurse, Unit Coordinators, Director and Assistant Director of Nursing on the new process of monitoring and responsibilities of this plan on 4/27/2021. Effective 04/27/2021, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. The facility alleged immediate jeopardy removal effective date 04/28/2021. On 04/30/2021, the facility's credible allegation for Immediate Jeopardy removal on 04/28/2021 was validated by the following: Observations of residents in the facility who used an indwelling urinary catheter revealed no symptoms of indwelling urinary catheter complications. Resident care plans included direction to assess for color, clarity, character of urine and to assess for urinary tract infection and blockages. Staff interviews revealed receipt of education regarding identification and response to indwelling urinary catheters. The facility implemented audit tools to monitor residents with indwelling urinary catheters reviewed by nursing management.

Based on a resident interview, staff interviews, and medical record review, the facility failed to use a gait belt when one staff person transferred Resident #5 from the bed to the wheel chair which resulted in a fractured right shoulder, right shoulder pain, an emergency department (ED) evaluation and orthopedic consult. This occurred for 1 of 3 sampled residents reviewed for safe transfers. The findings included: Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An annual Minimum Data Set, dated dated [DATE] assessed Resident #5 with intact cognition, adequate hearing, impaired vision (required corrective lenses), clear speech, with the ability to be understood and to understand. The Resident required extensive staff assistance of 2 persons with transfers, limited upper extremity range of motion (ROM) on one side and did not attempt a surface to surface transfer during the assessment period. A Resident Care Guide, updated [DATE] recorded Resident #5 required transfer assistance from 2 staff persons. Review of the facility's Resident Incident Report and Health Care Personnel Registry (HCPR) 24 Hour Initial Report, both dated [DATE], documented that on [DATE] around 3 PM, Resident #5 complained of right shoulder/arm pain. An X-ray was ordered and the results confirmed a shoulder fracture. The Director of Nursing (DON) interviewed Resident #5 on [DATE] around 3:20 PM. Resident #5 stated that nurse aide (NA) #1 from last night ([DATE]) pulled her arm twice, the Resident asked NA #1 to stop, but she didn't. NA #1 was suspended on [DATE] pending the outcome of the investigation. The Police Department was notified on [DATE] at 4:10 PM, responded and filed a report. Resident #5 was sent to the ED on [DATE] for further evaluation and returned with a physician's orders [REDACTED]. Review of the electronic medical record for Resident #5 revealed there was no documentation of an incident which involved the Resident on [DATE] or [DATE]. Review of the February 2018 electronic Medication Administration Record [REDACTED]. Medical record review for Resident #5 revealed the following physician's orders [REDACTED].>· [DATE] for a STAT (immediate) X-ray of right shoulder, right upper arm to rule out fracture · [DATE] for [MEDICATION NAME] (pain medication) 5 mg twice daily for 3 days due to complaints of right shoulder pain · [DATE] Send to (named hospital) for right humeral shaft fracture evaluation · [DATE] Follow up (named orthopedic) within 2 - 4 days · [DATE] Sling to right shoulder, pad strap if needed due to right minimally displaced proximal humerus fracture, will continue to watch with X-rays every 2 weeks, continue sling. Non weight-bearing right arm. Review of the HCPR 5 Day Working Report, dated [DATE] revealed Resident #5 denied being abused; the investigation unsubstantiated abuse, but NA #1 was terminated due the injury Resident #5 sustained. An interview on [DATE] at 1:00 PM with the DON revealed that on [DATE], Resident #5 reported pain to her right shoulder from a transfer on the ,[DATE] shift the night before to Nurse #2 and the staff development coordinator (SDC). The DON said when she was informed she, and the SDC, went to see the Resident on [DATE] around 3:20 PM. The DON stated Resident #5 repeated the same story to them as documented in the incident report. She said her story did not change. The DON stated she asked Resident #5 to demonstrate how her right arm was pulled and she did. The DON and SDC assessed the Resident's right arm, and during the assessment she complained of pain, and grimaced when ROM was attempted and when her arm was pressed. The DON said she was obviously in pain. The DON further stated that a stat X-ray was obtained with positive results for right shoulder fracture. Resident#5 was sent to the ED for further evaluation and returned with an orthopedic consult. The DON stated that the facility started an abuse investigation because of how Resident #5 described the incident, even though she did not use the word abuse. The investigation unsubstantiated abuse. NA #1 self-reported to Nurse #3 that she did not transfer Resident #5 with a gait belt as she had been trained and thought she may have injured the Resident. The DON described that Resident #5 could stand/pivot, and that one staff person using a gait belt could safely transfer the Resident despite the MDS assessment which indicated Resident #5 required the transfer assistance of 2 people. The DON stated I have transferred her many times by myself using a gait belt. The DON stated that since the incorrect transfer resulted in injury to Resident #5, NA #1 was terminated. The DON stated that she expected all staff to have a gait belt when transferring a resident and to use the gait belt if a mechanical device was not used. The DON stated she updated the Resident Care Guide for Resident #5 on [DATE] to reflect she needed transfers with 2 staff persons while her right shoulder healed. An interview occurred on [DATE] at 1:13 PM with Nurse #1 and revealed she worked routinely with Resident #5 on the 7 - 3 PM shift. Nurse #1 said she was informed by NA #2 on [DATE] during the 7 - 3 PM shift when Resident #5 complained of pain to her right arm. Nurse #1 said she immediately went to see Resident #5 and the Resident said that NA #1 got her up on the ,[DATE] AM shift and hurt her arm. Nurse #1 described Resident #5 as alert/oriented. Nurse #1 said when Resident #5 told her this, she gave her Tylenol for pain and informed her supervisor. Nurse #1 confirmed recent in-services on transfers/abuse. A telephone interview occurred with NA #1 on [DATE] at 1:40 PM and revealed she routinely worked with Resident #5 on the 11 - 7 AM shift. NA #1 stated she assisted Resident #5 with a transfer from her bed to her wheel chair towards the end of the 11 - 7 AM shift on [DATE]. NA #1 stated during the transfer, Resident #5's legs gave way, she dropped on me, I tried to keep her from hitting the floor, her right arm went up in the air, we heard a pop, and I immediately told the nurse. NA #1 further stated We were not using gait belts regularly before this, but the SDC started reminding us to use our gait belts. NA #1 stated Resident #5 required 1 staff person assistance with transfers because the Resident could stand and pivot. NA #1 described I was standing in front of her, I did not use my gait belt to transfer her, like I normally do, it was a lot going on that day, I had the gait belt but I did not use it for her transfer. NA #1 stated that she realized that was a mistake and that using the gait belt could have possibly prevented Resident #5 from getting hurt. NA #1 further stated that she really hated what happened to Resident #5 and wished it had not happened. An interview occurred on [DATE] at 1:58 PM with NA #2 and revealed she worked routinely with Resident #5 on the 7 - 3 PM shift. NA #2 described Resident #5 as alert/oriented. NA #2 stated that she was unaware of an incident that occurred with a transfer for Resident #5 until the Resident asked for assistance with incontinence care towards the end of the 7 - 3 PM shift. NA #2 said Resident #5 was in her wheel chair and during the transfer to her bed, the Resident complained of pain to her right shoulder. NA #2 stated she had checked on the Resident throughout the shift that day, but the Resident denied needing any assistance until then. NA #2 stated that Resident #5 did not complain of pain until the transfer from her wheel chair to her bed and she had to move her arm. NA #2 stated she immediately told Nurse #1. NA #2 confirmed she received recent in-services on abuse/transfers. Resident #5 was interviewed on [DATE] at 2:10 PM and observed wearing a right arm sling. During the interview, Resident #5 said that few weeks ago, NA #1 transferred her alone, without a gait belt and during the transfer, the Resident's legs got weak and NA #1 pulled on her arm twice to help her stand. Resident #5 said they heard a pop the second time and NA #1 left out of her room to get the nurse. Resident #5 said Nurse #1 came in and looked at her arm, But it was not hurting then, I did not have pain right away, it did not start hurting until later in the day when the other NA came to clean me up and put me to bed. Resident #5 confirmed that when she did complain of pain, she was medicated, her arm was assessed, X-rayed and she was sent to the ED for evaluation. Resident #5 also stated that NA #1 routinely transferred her alone, sometimes with a gait belt and sometimes without. Resident #5 confirmed she was interviewed by staff about abuse/transfers. A telephone interview with Nurse #3 occurred on [DATE] at 3:30 PM and revealed she routinely worked with Resident #5 on the 11 - 7 AM shift. She described Resident #5 as alert/oriented. Nurse #3 stated at change of shift on [DATE] around 6:45 AM, NA #1 came to her and said I was transferring (Resident #5), not the way I usually do and I think I hurt her arm. Nurse #3 stated she went immediately and assessed Resident #5, the Resident denied pain and there was no sign of injury when ROM was performed. Resident #5 said she was fine. Nurse #3 said she did not report the incident or document a progress note. Nurse #3 confirmed she received recent in-services on transfers/abuse. An interview with the Administrator on [DATE] at 5:07 PM revealed he expected NA #1 to transfer Resident #5 with a gait belt for safety. The Administrator stated NA #1 had been trained on how to safely transfer a resident with 1 person assistance and she should have followed the facility's policy/procedures on safe transfers. The administrator stated the following corrective action had been completed as of [DATE] for Past Non-Compliance: · Quality Assurance Performance Improvement Committee met and developed a plan · All staff were in-serviced on transfers/abuse; any prn (as needed) staff could not work until they were re-educated. · Residents were interviewed regarding safe transfers/abuse · Resident care guides were audited/updated regarding transfer status · Staff compared nurse's notes with incident reports to make sure all incidents were reported timely · Management staff monitored transfers and were currently monitoring 6 residents/6 employees each week to ensure they were aware of the procedure for reporting abuse, and conducting safe transfers · Staff reviewed orientation packets to make sure it contained up-to-date information regarding abuse/transfers · The facility continued to monitor/audit for ongoing compliance The facility provided documentation of training for NA #1 in [DATE] on the use of gait belts with transfers. The facility also provided documentation of corrective action as of [DATE] for in-services, audits and monitoring related to safe transfers, resident interviews and updated Resident Care Guides. At the time of the survey, sampled residents were observed transferred safely according to the transfer status documented on their Resident Care Guide. Interviews with alert/oriented residents revealed they were transferred according to the transfer status on their Resident Care Guide and they felt safe. Interviews with staff revealed they were aware of the facility's revised policy/procedures for safe transfers and preventing/reporting abuse.

Based on observations, staff and nurse practitioner interviews, and record review, the facility failed to conduct weekly skin assessments for 1 of 3 sampled residents with pressure sores (Resident #172). The findings included: Resident #172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #172's admission Minimum Data Set ((MDS) dated [DATE] revealed an assessment of severely impaired cognition with independence in bed mobility. The MDS coded Resident #172 with frequency or urine and bowel incontinence. The MDS indicated Resident #172 was at risk for pressure sore development with no pressure sores upon admission. Review of Resident #172's care plan dated 04/02/14 revealed a risk for skin integrity impairment with a goal of no skin breakdown. Interventions included pressure reduction mattress, wheelchair cushion and weekly skin checks by nurse. Review of Resident #172's skin inspection reports revealed one report dated 04/01/14 which documented intact skin. Review of physician's orders [REDACTED]. Review of Resident #172's April 2014 Treatment Record revealed weekly skin checks scheduled for the 3 to 11 shift every Tuesday. A skin check was initialed as completed on 04/01/14. There were no nurses' initials written on blocked out dates of 04/08/14, 04/15/14, 04/22/14 and 04/29/14. Review of Resident #172's May 2014 Treatment Record revealed weekly skin checks scheduled to be conducted on the 3 to 11 shift every Tuesday. There were no nurses' initial written on the blocked out date of 05/06/14. Review of a nursing note dated 05/12/14 revealed three 0.25 centimeters (cm.) by 0.25 cm. open areas, one 2 cm. by 2 cm. open area and one 1.5 cm. by 1 cm. open area on Resident #172's buttocks. Nurse #2 notified the physician and received orders for treatment of [REDACTED]. Review of the wound assessment report dated 05/13/14 revealed the following descriptions of 5 new open areas: ? Stage 2 pressure ulcer on the right buttock with measurements of 1.5 cm. by 2.0 cm. by 0.10 cm. ? Stage 2 pressure ulcer on the right buttock with measurements of 1.0 cm. by 1.0 cm. by 0.10 cm. ? Stage 2 pressure ulcer on the right buttock with measurements of 0.5 cm. by 0.5 cm. by 0.10 cm. ? Stage 2 pressure ulcer on the right buttock with measurements of 0.5 cm. by 0.5 cm. by 0.10 cm. ? Stage 2 pressure ulcer on the sacrum with measurements of 2.50 cm. by 0.50 cm. by 0.10 cm. Interview with Nurse #1 on 05/14/14 at 9:29 AM revealed she did not complete the assigned weekly skin assessments for Resident #172. Nurse #2 explained she was new to the position and thought she "might have missed a few." Nurse #2 was unable to locate weekly skin check forms. Nurse #2 reported Resident #172 transferred to another nursing unit on 05/09/14. Observation on 05/15/14 at 10:22 AM revealed Nurse #3 changed Resident #172's dressing on the right buttock and sacrum. The soiled dressing contained a small amount of non-odorous yellow drainage. The sacral pressure sore was approximately 2.5 cm. by 1.0 cm by 0.1 cm. The pressure sore on the right buttock was approximately 2.0 cm. by 3.5 cm by 0.10 cm. Telephone interview with Nurse #1 on 05/15/14 at 10:39 AM revealed Nurse Aide (NA) #1 reported the open areas on 05/12/14. Nurse #1 reported she notified the physician and Resident #172's family member. Interview with the Director of Nursing on 05/15/14 at 11:02 AM revealed Resident #172 did not receive a weekly skin assessment. The DON reported he expected the nurse to conduct a weekly skin assessment. The DON explained NAs also checked residents' skin every shower day. The DON provided a shower check sheet dated 05/10/14 which indicated Resident #172 refused a shower and had no skin problems. NA # 2, who completed the shower sheet dated 05/10/14, was not available for interview. Interview with Nurse #4 on 05/15/14 at 11:39 AM revealed four of the five pressure sores changed into one pressure sore on the right buttock since her assessment of the Stage 2 pressure sores on 05/13/14. Nurse #4 reported Resident #172's two Stage 2 pressure sores would be assessed by the Nurse Practitioner (NP). Interview with NA #3 on 05/15/14 at 12:10 PM revealed she cared for Resident #172 prior to the transfer to a new nursing unit of 05/09/14. NA #3 explained Resident #172 required extensive assistance with transfers but did not require repositioning in bed. NA #3 reported she would report any skin changes to the nurse and did not see any changes with Resident #172. Interview with the NP on 05/15/14 at 2:09 PM revealed she examined Resident #172's pressure sores and Resident #172's medical conditions placed her at risk for pressure sore development. The NP explained a likely contributing factor was shearing and then the areas worsened.

Based on observation, staff and nurse practitioner interviews, and record review, facility staff failed to assess a resident with complaint of pain for 1 of 4 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted [DATE]. [DIAGNOSES REDACTED]. The resident was assessed as non ambulatory. Review of incident report dated 02/01/13 at 2:00 PM revealed a family member informed Nurse #1 that earlier that morning Resident #1 was being propelled in her wheelchair by a therapist, and her right leg bent back under the wheelchair. Incident report stated "resident presents with raised area to right shin and to right side of the knee." Review of treatment encounter notes dated 02/01/13 revealed Resident #1 was transported to the therapy department by physical therapy assistant (PTA) #1 for 30 minute therapy session. PTA #1 progress notes revealed Resident #1 experienced buckling of bilateral lower extremities and complained of right lower extremity pain during therapy. Record review revealed the nurse practitioner was notified with new orders received. Review of xray results of the right tibia/fibula dated 02/01/13 revealed minimally displaced tibia/fibula fracture. Interview on 04/26/13 at 5:15 PM with PTA #1 revealed she transported Resident #1 in her wheelchair to her therapy session on 02/01/13. PTA #1 reported Resident #1 was transported routinely with her legs held up while staff pushed the wheelchair. PTA #1 stated Resident #1 planted her feet on the ground unexpectedly while she continued to push the wheelchair forward and both legs were bent back under the wheelchair. PTA #1 stated Resident #1 said "oh my leg." PTA #1 stated she stopped the wheelchair immediately and straightened the resident's legs out from under the wheelchair. PTA #1 stated she directed the resident to hold her legs up and continued to transport the resident to therapy. PTA #1 stated Resident #1 complained of right leg pain during therapy but stated she did not think anything of it because "she always complained of pain." PTA #1 stated she continued with the therapy session and then returned the resident to her unit and notified the nurse of the resident's complaint of pain. Interview on 04/23/13 at 2:40 PM with PTA #2 stated he assisted PTA #1 with Resident #1 during therapy on 02/01/13. PTA #2 stated he assisted with the resident's sit to stand exercises. PTA #2 stated the resident was unable to perform the exercises and was assisted back to her wheelchair. PTA #2 stated the resident moaned in pain with facial grimacing. PTA #2 stated PTA #1 moved the resident to another part of the therapy department to continue with other exercises. Review of Nurse #1 written statement (undated) revealed PTA #1 returned Resident #1 to the unit and reported the resident's complaint of right leg pain. Review of written statement revealed Nurse #1 was not notified of the incident with the wheelchair and complaint of right leg pain at the time of the incident. The written statement indicated Nurse #1 assessed Resident #1 when she returned to the unit and observed a raised area on the right leg with [MEDICAL CONDITION]. The written statement indicated no complaint of pain with palpation. The resident was medicated for pain, and the nurse practitioner (NP) making rounds in the facility was notified. The written statement indicated Resident #1 was taken to the dining room for lunch but had poor intake. Meal intake was encouraged but the resident stated she was "hurting too bad to eat." Attempts to contact Nurse #1 were unsuccessful. Interview on 04/23/13 at 1:47 PM with the NP revealed she was notified and assessed Resident #1 on 02/01/13. The NP stated she assessed the resident with swelling to the right leg with pain to touch. The NP stated xray results confirmed right leg fracture and indicated [MEDICAL CONDITION]. The NP stated she discussed treatment options with the family. The family decided to proceed with conservative treatment and the resident was placed in an immobilizer with no hospitalization or surgical repair. An interview was conducted on 04/23/13 at 1:00 PM with the Administrator and Director of Nursing. Interview revealed all facility staff are expected to provide timely notification of any incident or change in condition to ensure prompt assessment and treatment as indicated.

Based on staff interviews and medical record reviews, the facility failed to immediately implement emergency medical interventions and initiate Cardiopulmonary Resuscitation (CPR) as specified by the Advanced Directives for one (1) of six (6) residents. (Resident #1) Immediate jeopardy began on [DATE] when Resident #1 did not receive immediate emergency medical interventions including CPR and calling 911 for a resident who had a full code status. Immediate Jeopardy was removed on [DATE] following staff education. The facility remains out of compliance at a lower scope and severity of D, an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy, while the facility monitors the effectiveness of the staff education. The findings are: An undated facility policy titled "Cardiopulmonary Resuscitation (CPR)" included the following: - CPR is provided when the resident's Advanced Directive specifies such, or when there is NO Advance Directive to contraindicate CPR administration.. - Upon finding the resident, call for help. Certified personnel should attend to the resident while other staff make emergency calls and retrieve resuscitation equipment. - Observe for symptoms of [MEDICAL CONDITION]: loss of consciousness, absence of carotid or femoral pulses, absence of audible heart sounds, absence of breath sounds. - If no pulse is observed, tilt head back and give two (2) quick, full, long inflations. - Check for pulses again. - If pulses are absent, begin cardiopulmonary resuscitation. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. The Interdisciplinary Assessment completed during admission indicated impairment of memory and cognition and dependence on staff assistance for all daily care. The nursing admission note indicated the resident was scheduled for feeding tube placement [DATE]. Medical record review revealed a document titled "Full Code Agreement," which included text as follows: "This is to acknowledge that this resident is a full code. If the resident is found to have no heart rhythm or respirations, then full measures will be implemented." The document was signed [DATE] by the Guardian for Resident #1. The admission note written [DATE] by the Social Worker noted, "Full code is in effect." The History and Physical signed by the physician [DATE] indicated the resident's code status was full code. Review of nursing documentation of [DATE] revealed the following note written at 6:39 a.m. by Licensed Nurse #1: "Resdt (resident) observed not to be breathing. 0 (No) resp (respirations). 0 pulse. On call physician paged. Awaiting him to call back. Guardian notified by leaving message with the answering services. CPR initiated. 911 notified. Resdt pronounced dead by EMS (Emergency Medical Services)." During an interview on [DATE] at 1:20 p.m., the Director of Nursing (DON) stated the policy and procedure for medical emergencies included overhead page of code blue, call to 911, and call to the physician. The nurse is responsible for verifying the code status in the chart. If a resident is full code status, CPR should be started immediately. The DON stated the resident's code status is considered a physician's orders [REDACTED]. The DON stated the nurse responsible for the resident's care on [DATE] was CPR certified, but did not page the emergency overhead and did not immediately start CPR, and his actions were based on his assessment that the resident was deceased . The DON stated nurses are not qualified to pronounce the death of a resident. On [DATE] at 9:55 a.m., interview with Licensed Nurse (LN) #1 revealed he was responsible for the resident's care [DATE]. LN #1 stated he was passing medications and found the resident without pulse and respirations when he entered her room at 6:39 a.m. LN #1 stated he thought the resident's death was "expected," and he left the room and reported to the supervisor (LN #3) the resident had expired. LN #1 stated the supervisor told him to go and check the chart to verify code status, and he went to the nurse's station to check the chart. LN #1 stated he saw the full code status, called to notify the physician, and called the guardian to notify of the resident's death. He stated the on-call physician returned the call and directed him to follow the order for code status, and start CPR and call 911. When questioned about his actions, LN #1 stated he did not start CPR immediately because she was cold and had no pulse and respirations. LN #1 stated, " She was dead." LN #1 stated pronouncing death was not in his scope of practice as a Licensed Practical Nurse. LN #1 said after making the calls, LN #3 and NA (Nursing Assistant) #3 were in the room to help him with the code. On [DATE] at 11:00 a.m., the resident's physician was interviewed. The physician stated once the nurse determined full code status for Resident #1, he/she should have immediately started CPR and called 911. The physician stated his expectation is for nursing staff to, without exception, follow orders for code status. The physician stated determination of death is not the responsibility of the nurse. On [DATE] at 1:30 p.m., interview with LN #2 revealed she arrived late to work on [DATE], at approximately 7:30 a.m. LN #2 stated EMS arrived after she arrived at work. During an interview on [DATE] at 2:50 p.m., LN #3 stated she received the report the next night during the 7:00 p.m.-7:00 a.m. shift that Resident #1 had expired. Review of call and arrival times for EMS revealed the call was received by EMS at 7:44 a.m., and EMS personnel arrived in the facility at 7:47 a.m. Review of the facility's investigation of the incident revealed statements were taken only from LN #1 and NA #3. The written statements included the following: NA #3 noted the resident was last seen on [DATE] at approximately 5:15 a.m. during rounds. The NA reported the resident was alive, and was turned and repositioned at that time. LN #1 documented on [DATE] at approximately 6:40 a.m., he went into the resident's room to give medications and found the resident had expired. LN #1 stated he went to notify his supervisor (LN #3) and informed her that the resident's death was expected, then proceeded to call the on-call physician. During the call to notify the physician, LN #1 noted he realized the resident's full code status and informed the on-call service. The Nurse Practitioner on-call for the physician returned the call within a few minutes and directed LN #1 to call 911 and initiate CPR based on the resident's code status. EMS was in the resident's room within a few minutes, and pronounced death. Review of the facility's staff education provided [DATE] following the event revealed an inservice was provided to approximately 25 licensed staff. No provision was made to include staff members unavailable at the time of the inservice or prn (as needed) employees not scheduled for work, or for new employees to receive the education. Unlicensed staff (NAs) were not included in the inservice. The content of the inservice included the following: "It is imperative that as a licensed nurse you do rounds on your patients. Your rounds should be opposite of your C.N.A.'s rounds so your patients will be checked on hourly (night shift nurses especially). If a patient is found in your opinion without signs of life and he/she is a FULL CODE you must immediately begin CPR until EMS or Fire Dept arrives and takes over the situation no matter what the patient's condition is (Rigor mortis, cold, blue, vomited, etc ...). This is because you are not qualified to pronounce a patient as being deceased ." The DON was interviewed on [DATE] at 3:25 p.m. No explanation was offered for the nurse's failure to immediately intervene in the resident's medical emergency. The DON stated that nurses should follow the resident's Advanced Directive for code status, and based on this resident's designated code status, the facility procedures for code blue should have been initiated when the resident was discovered without a pulse and respirations. The survey was extended on [DATE], and the Administrator was informed of Immediate Jeopardy (IJ) on [DATE] at 3:00 p.m. for Resident #1. The facility presented a credible allegation of compliance which included: 1. Correction for Resident #1 Resident #1 has expired. 2. Correction for current residents at risk [DATE] and [DATE]. ? An audit of all resident charts was conducted on [DATE] and [DATE] by the Resident Care Coordinators and the MDS Coordinators to ensure that each resident's code status is clearly defined in the Medical Record. A list of residents with a FULL CODE status was placed in the front of each Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ? All newly admitted resident's code status is obtained by the Admissions Coordinator and placed in the admissions packet and given to the admitting nurse. Admitting nurse is verifying the code status with the resident/family and is contacting the physician for verification prior to placing in the clinical record. The admitting nurse is updating the CODE status list in the MAR indicated [REDACTED] ? The newly admitted resident's chart is audited within 24 hours by nursing administration to ensure that the Advanced Directives are clear and accurate. The Director of Nurses will be notified immediately of any variance from the procedure and inform her of the corrections that were made. A complete audit is reported to the Director of Nurses weekly. ? Nurse involved with Resident #1 is no longer employed by facility. 3. In-service: In-service was conducted on [DATE] and [DATE] by the Director of Nurses, Assistant Director of Nurses/Staff Development Coordinator and the Vice President of Clinical Services and included the following: 88% of Full time, 68% of Part time and 22% of PRN staff that have direct access to residents (Nursing, housekeeping, maintenance, medical records, Administrator, Dietary manager, business office personnel) were re-educated on [DATE] and [DATE] regarding the initiation of CPR and have been notified of residents with FULL CODE status. The remaining 12% of Full Time, 32% of Part time and 78% of PRN staff will be re-educated prior to working. Education includes: a. If a resident is found unresponsive, pull emergency call light and summon a Nurse STAT. b. The nurse will assess the resident while another nurse checks the medical record for the code status. If the code status is FULL CODE, immediately page "code blue" via the overhead page and initiate CPR. c. Call 911. d. Call the MD e. Call the family. f. If the resident is determined to be a DNR status, call the MD and the family. g. The Charge Nurse and/or the assigned Nurse will notify The Director of Nursing immediately if a resident with a FULL CODE status has been resuscitated or has expired to allow her to determine that appropriate procedures were followed. Nurses have been educated additionally on [DATE] and [DATE] by the Director of Nurses, Assistant Director of Nurses/Staff Development Coordinator and the Vice President of Clinical Services and included the following: Residents who are FULL CODE are listed in front of the MAR books for each unit. Nurses will monitor residents with noted decline in condition with a terminal [DIAGNOSES REDACTED]. The resident will be assessed every hour for signs and symptoms of decline and imminent death with findings of assessment documented in clinical record and the 24 hour report sheet. The Charge Nurse will participate in the evaluation and decisions regarding the care of the resident. Findings of assessment will be documented on the 24 hour report and the physician notified as indicated by code status and directives related to hospitalization , medication, and life sustaining measures. Certified Nursing Assistants have been educated on [DATE] and [DATE] by the Director of Nurses, Assistant Director of Nurses/Staff Development Coordinator and the Vice President of Clinical Services additionally on the following: C.N.As will notify the nurse of any difference in the residents' appearance or behavior. All newly hired employees will be in-serviced by the Assistant Director of Nurses/Staff Development Coordinator regarding determination of resident's CODE status and initiation of CPR to include the following: Education includes: a. If a resident is found unresponsive, pull emergency call light and summon a Nurse STAT. b. The nurse will assess the resident while another nurse checks the medical record for the code status. If the code status is FULL CODE, immediately page "code blue" via the overhead page and initiate CPR. c. Call 911 d. Call the MD e. Call the family. f. If the resident is determined to be a DNR status, call the MD and the family. g. The Charge Nurse and/or the assigned Nurse will notify The Director of Nursing immediately if a resident with a FULL CODE status has been resuscitated or has expired to allow her to determine that appropriate procedures were followed. Newly hired Nurses will be educated by the Assistant Director of Nurses/Staff Development Coordinator during the orientation process prior to being assigned to the unit additionally on the following: Residents who are FULL CODE are listed in front of the MAR. Nurses will monitor residents with noted decline in condition with a terminal [DIAGNOSES REDACTED]. The Charge Nurse will participate in the evaluation and decisions regarding the care of the resident. Findings of assessment will be documented on the 24 hour report and the physician notified as indicated by code status and directives related to hospitalization , medication, and life sustaining measures. The Charge Nurse and/or the assigned Nurse will notify The Director of Nursing immediately if a resident with a FULL CODE status has been resuscitated or has expired to allow her to determine that appropriate procedures were followed. The Charge Nurse will review the residents' clinical record at that time to ensure that the CODE status is being followed as well as evaluate the procedure. The Charge Nurse will report to the Director of Nurses any variances to the procedure. Newly Hired Certified Nursing Assistants will be educated additionally during orientation and prior to working on the unit by the Assistant Director of Nurses/Staff Development Coordinator additionally on the following: C.N.As will notify the nurse of any difference in the residents' appearance or behavior. 4. Monitoring: [DATE] Residents with noted decline in condition with a terminal [DIAGNOSES REDACTED]. The Charge Nurse will participate in the evaluation and decisions regarding the care of the resident. Findings of assessment will be documented on the 24 hour report, and in the clinical record and the physician notified as indicated by code status and directives related to hospitalization , medication, and life sustaining measures. The Charge Nurse and/or the assigned Nurse will notify the Director of Nursing immediately if a resident with a FULL CODE status has been resuscitated or has expired to allow her to determine that appropriate procedures were followed. The Charge Nurse will review the residents' clinical record at that time to ensure that the CODE status is being followed as well as evaluate the procedure. The Charge Nurse will report to the Director of Nurses any variances to the procedure. Any CODE status changes will be written on the 24 hour report by the nurse transcribing the order, the clinical record will be updated and the MAR FULL CODE list will be updated by that nurse at that time. The 24 hour report and all physicians' orders are being reviewed by nursing administration (Director of Nurses, Assistant Director of Nursing, Resident Care Coordinator and MDS Coordinators) during morning clinical rounds to identify any clinical status changes and to verify that CODE status was followed. The chart will be audited and updated as needed at that time by nursing administration to ensure that CODE status has been updated where necessary within the residents' clinical record and the MAR. The Resident Care Coordinator for each unit will audit the MAR FULL CODE list weekly to ensure that it is updated and correct with a report to the director of nurses weekly. The Director of Nursing will audit 10 charts weekly to ensure that the Advance Directives remain in place and are correct x 1 year. In the absence/unavailability of the Director of Nurses the Assistant Director of Nurses will complete audits. The Director of Nurses or Assistant Director of Nurses will report findings of the chart and MAR FULL CODE list audits to the QA& A Committee monthly x 12 months. The QA&A Committee will evaluate findings and determine if changes to the plan are needed to assure continued compliance. The Resident Care Director (Social Worker) will audit 100% of residents' CODE status quarterly for changes in CODE status and to ensure that documentation is present and correct. Immediate jeopardy was removed on [DATE] at 4:30 p.m. with interviews of direct care staff and licensed nursing staff confirming that they had received inservice training on the unresponsive resident and code blue initiation. Interviews with nursing staff revealed awareness of how to respond and implement measures for an unresponsive resident without pulse or respiration. Reassessment of residents' code status was completed by administrative nursing staff and social services. Code listings for residents designated full code status were updated and placed in the front of the Medication Administration Records (MARs). Observations were made to ensure accurate full code status listings were available in the MARs.